DefinePK

Abstract

Background: Transurethral resection of bladder tumor (TURBT) is an important procedure performed for diagnosing and managing bladder cancer. Proper documentation of TURBT operative notes is essential for risk stratification and treatment planning. However, handwritten notes often lack critical details, which may compromise patient care. Aim: To evaluate the quality of handwritten TURBT operative notes against standard EAU guidelines and assess the impact of implementing a structured proforma to improve documentation at Safari Hospital, Bahria Town, Rawalpindi, Pakistan. Materials & Methods: We conducted a closed-loop clinical audit over one year, assessing 108 operative notes. In the initial audit, 45 handwritten TURBT operative notes were evaluated against standardized checklist. A structured proforma was then introduced, designed to improve compliance with EAU guidelines. A re-audit was performed to assess improvements in documentation quality with 63 notes. Data were analyzed using descriptive statistics, and a paired-sample t-test was used to assess statistical significance. Results: Comparison between the first and second audits demonstrated significant improvements in documentation quality. In the initial audit, compliance with essential parameters was suboptimal, with several details missing. Following the introduction of the proforma, documentation rates improved, with multiple parameters reaching 100% compliance. The paired-sample t-test confirmed these improvements were statistically significant (p = 0.001). Conclusion: The introduction of standardized proforma significantly improved adherence to guidelines, completeness, and accuracy of TURBT operative notes. Implementing structured proformas across institutions can improve surgical documentation practices and contribute to better patient outcomes.