Elevating orthopedic documentation: a clinical audit of orthopaedic operative note quality against RCSE and BOA standards
Ajay Kamat, Ashvath Arumugam Pillai, Upasna Ajmani, Sai Pasya · 2026
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Description
Surgery notes at a tertiary hospital fell short of national standards, an audit by Ajay Kamat and colleagues shows, and a simple fix lifted them. The 2026 clinical audit compared orthopaedic operative notes against standards from the Royal College of Surgeons of England and the British Orthopaedic Association.
One hundred notes from early 2023 were scored first: patient identification appeared in 72%, intraoperative findings in 65%, the postoperative plan in 58%, and surgeon details in 70%. The department then introduced a standard note template plus staff training and re-audited another hundred notes. Every domain rose sharply, and overall adherence climbed from 68% to 95%. Kamat and colleagues recommend building note training into induction for rotating staff to hold the gains.
Catalog record
| CREATOR | Ajay Kamat, Ashvath Arumugam Pillai, Upasna Ajmani, Sai Pasya |
|---|---|
| YEAR | 2026 |
| COLLECTION | PAPERS |
| FORMAT | TXT |
| FILE SIZE | 20798 |
| LICENSE | https://creativecommons.org/licenses/by/4.0 |
| RIGHTS | CC BY |
| SOURCE | Europe PMC |