An audit of the quality of operation notes in an otolaryngology unit.
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.
Bateman
N D
ND
Department of Otolaryngology-Head & Neck Surgery, Queen's Medical Centre, Nottingham, UK.
Carney
A S
AS
Gibbin
K P
KP
D019985:Benchmarking; D006801:Humans; D016365:Liability, Legal; D008318:Malpractice; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D010036:Otolaryngology / Q000592:standards*; D013517:Otorhinolaryngologic Surgical Procedures / Q000706:statistics & numerical data*; D011786:Quality Control; D014956:Writing / Q000592:standards