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J Maxillofac Oral Surg. 2011 Sep;10(3):203-8. doi: 10.1007/s12663-011-0231-z. Epub 2011 May 6.

Improving the Standard of Operative Notes within an Oral and Maxillofacial Surgery Department, using an Operative Note Proforma.

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Department of Oral and Maxillofacial Surgery, Royal Derby Hospital, Uttoxeter Road, DE22 3NE Derby, UK.



The operative note needs to be an accurate and legible account of events occurring in the surgeon's theatre. We set out to discover if operative notes within a British District General Oral and Maxillofacial Surgery department adhered to Royal College of Surgeons (England) guidelines.


We audited 100 consecutive Oral and Maxillofacial Surgery operations performed within general theatres. As an intervention we designed and piloted a paper based Operative Note Proforma and re-audit was undertaken.


Initial audit showed results lacking in certain areas. At re-audit all audit criteria showed improvement. The mean percentage of data point inclusion rose from 76.1 to 98.3% (0.001 < P-value < 0.005).


Previous papers have discussed various methods of improving operative note standards. We present statistical evidence for the use of an Operative Note Proforma to improve operative note standards within Oral and Maxillofacial Surgery.


Audit; Operation note; Operative note

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