title: Improving operation notes and postoperative care: an audit of current practice.
abstract: The operation note is the single most important document in surgical practice. Ninety one operation notes were assessed on their adherence to guidelines, as well as their legibility and ability to inform postoperative care; as judged by five different healthcare professionals. Results showed a deficiency in essential information and poor legibility overall. Re-audit of 103 operation notes after intervention showed an improvement in nearly all criteria measured. The results indicate that education about current guidelines and an increase in word processing of operation notes improves quality of documentation, and therefore of postoperative care.
authors: T
authors: T
authors: Whitehead-Clarke
authors: N
authors: N
authors: Varma
authors: A
authors: A
authors: Hadjimichael
authors: F
authors: F
authors: Gillham
authors: K
authors: K
authors: O'Brien
mesh_terms: D004282:Documentation; D008485:Medical Audit; D010348:Patient Care Team; D011182:Postoperative Care / Q000592:standards*; D013514:Surgical Procedures, Operative; D006113:United Kingdom