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 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.


CONCLUSIONS
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.
Lefter
Liviu P
LP
Department of Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia. lilefter@gmail.com
Walker
Stuart R
SR
Dewhurst
Fleur
F
Turner
R W L
RW
D005568:Forms and Records Control; D006784:Hospitals, Teaching; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards*; D013514:Surgical Procedures, Operative