Evaluation of operative notes concerning laparoscopic cholecystectomy: are standards being met?

World Journal of Surgery
L S G L WaubenJ F Lange

Abstract

Laparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon's operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC. Nine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the "not described" items were performed. All hospitals participated. Most notes complied with the Dutch guideline (52-69%); 19-30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient's posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and...Continue Reading

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Citations

Apr 3, 2016·American Journal of Otolaryngology·Cheryl C NoconAlexander J Langerman
Jul 20, 2010·The Surgical Clinics of North America·Yuhsin V Wu, David C Linehan
Sep 17, 2015·Journal of Laparoendoscopic & Advanced Surgical Techniques. Part a·Paul R A O'MahoneyJeffrey W Milsom
May 6, 2015·Journal of Clinical Nursing·Sandra BraafElizabeth Manias
Jun 15, 2011·International Journal of Nursing Studies·Sandra BraafRobin Riley

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