Abstract:
Post-operative notes (PON) documentation following caesarean section (C/S) is crucial for subsequent management of patients after the surgery. No study has ever been done in our setting to assess the contents of PON. The aim of this study was to evaluate the completeness of written PON from C/S at Muhimbili National Hospital (MNH).
Methodology
One thousands two hundred PON were reviewed against pre developed criteria. Each note was assessed for completeness of the criteria developed. The criteria were developed by reviewing literature and discussion with doctors in the department of Obstetrics and Gynecology. The persons who performed the C/S were identified, either registrars/residents or specialists. Analysis was done using Statistical Package for Social Sciences (SPSS) version 20 and results were presented as frequency tables.
Results
Among 1200 PON reviewed,833 were emergencies and 367 were elective C/S. Registrars/residents wrote 68.5% of the PON, and specialists wrote 30% of them. The main indication for C/S was previous scar (26.2%) followed by CPD/obstructed labor/big baby (17.5%). Four post operative notes (0.3%) were complete. Four criteria (indication of C/S, intravenous antibiotics, pain management and intravenous fluids) came out to be present in all PON. The criteria with deficiencies varied from 99.8% for the highest to 2% for the lowest. Difference in writing PON between registrars/residents and specialists were noted in: washing and draping, type of uterine closure, suture used for uterine closure, swab and instrument count, appearances of fallopian tubes and ovaries. P-value for those elements was< 0.001.
Conclusion
Few PON met the agreed criteria. Differences of contents of the notes between registrars/residents and specialists were noted in some of the criteria. There is a need for a standard national guideline for operative notes documentation. A checklist can also be available in theatre, to remind surgeons on what type of information is needed to help in patient’s care post surgery.
