Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma.

Abstract

Comprehensive documentation of surgical procedures is an essential component of good medical practice, but the standard of operation notes in orthopaedic and trauma surgery has been notoriously poor. The value of proformas in the production of high standard operation notes has been demonstrated in various surgical specialities. We have compared the standard of documentation of operation notes before and after the introduction of a proforma and report a significant improvement (P < 0.001) with the proforma. In addition, the results from a neighbouring hospital where a similar proforma was in use show a sustained standard of documentation 5 years after it was first used.