Abstract
Hand-written operation notes are often produced as evidence in medico-legal cases. Incomplete and illegible notes, along with the use of confusing abbreviations, are a common source of weakness in a surgeon's defence. An audit of 100 sets of operation notes was carried out in a single otolaryngology department. Notes were scrutinised for the accuracy of data, ward, department and name of surgeon, as well as for the inclusion of unacceptable abbreviations. Using an aide-memoire attached to the front of the operation sheet, the audit was repeated with identical criteria. The aide-memoire improved the standard of operation note with respect to all measured criteria. Clear identification of operating surgeon improved from 74% to 93%, and the avoidance of unacceptable abbreviations rose from 53% to 84%. We conclude that a simple aide-memoire attached to operation note sheets can significantly improve the quality of note-keeping and potentially avoid medico-legal problems.
Original language | English |
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Pages (from-to) | 94-95 |
Number of pages | 2 |
Journal | Journal of the Royal College of Surgeons of Edinburgh |
Volume | 44 |
Issue number | 2 |
Publication status | Published - Apr 1999 |
Externally published | Yes |
Keywords
- Audit
- Medico-legal
- Operation note