An audit of the quality of operation notes in an otolaryngology unit

Neil D. Bateman, A. Simon Carney, Kevin P. Gibbin

Research output: Contribution to journalArticlepeer-review

37 Citations (Scopus)

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 languageEnglish
Pages (from-to)94-95
Number of pages2
JournalJournal of the Royal College of Surgeons of Edinburgh
Volume44
Issue number2
Publication statusPublished - Apr 1999
Externally publishedYes

Keywords

  • Audit
  • Medico-legal
  • Operation note

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