AN AUDIT OF OPERATIVE NOTES: FACTS AND WAYS TO IMPROVE

Background:  Accurate operation record keeping is an important element of risk management. Handwritten surgical notes are often produced as evidence in medico‐legal malpractice cases and incomplete and illegible notes may be a source of weakness in a surgeon’s defence. Therefore, we audited the surg...

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Bibliographic Details
Published in:ANZ journal of surgery 2008-09, Vol.78 (9), p.800-802
Main Authors: Lefter, Liviu P., Walker, Stuart R., Dewhurst, Fleur, Turner, R. W. L.
Format: Article
Language:English
Subjects:
computerized database
Forms and Records Control
Hospitals, Teaching
Humans
legibility
Medical Audit
Medical records
Medical Records - legislation & jurisprudence
Medical Records - standards
operation notes
Risk management
Surgery
Surgical Procedures, Operative
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Summary:Background:  Accurate operation record keeping is an important element of risk management. Handwritten surgical notes are often produced as evidence in medico‐legal malpractice cases and incomplete and illegible notes may be a source of weakness in a surgeon’s defence. Therefore, we audited the surgical notes in a teaching hospital surgical department. Methods:  During 1 week 190 operative notes were audited for patient identity details, preoperative diagnosis, operation title and details, CMB code, postoperative instruction and author of the note. The operative notes were assessed by a medico‐legal lawyer and a medical expert to establish level of legibility and usefulness in a virtual court case. Results:  Several operative notes were found incomplete (51.57%) missing important information as CMB code (13.68%), patient details (6.8%) preoperative diagnosis (6.31%), operation title (6.31%) and postoperative instruction (14.73%). Overall, only 92 notes were complete. Conclusion:  This audit suggests that handwritten surgical notes generate several errors that could lead to confusion when notes are reviewed for further follow up or are produced as evidence in medico‐legal disputes.
ISSN:1445-1433
1445-2197
DOI:10.1111/j.1445-2197.2008.04654.x