title: Standards in Operation Notes--Is It Time to Re-Emphasise Their Importance?
abstract: Guidelines exist for operation notes from the Royal College of Surgeons of England but compliance has been shown to be variable. The authors performed a closed loop audit of compliance with RCS standards in an Irish Plastic Surgery department. Thirty random operation notes were selected from a conserved pool of authors--before and after an educational intervention to increase awareness of the RCS guidelines. Following education, improvements were noted but also deteriorations--time increased from 12 (40%) to 16 (53%), emergency/elective status from none (0%) to 11 (36%), and operative diagnosis from seven (23%) to 21 (70%). However notably among the findings, surgeon's name decreased from 30 (100%) to 26 (86%), findings from 27 (90%) to 21 (53%) and tissue altered from 27 (90%) to 20 (66%). As some specialities are developing operation note standards specific to individual procedures, the findings are compared with previous similar published work.
authors.forename: K C
authors.initials: KC
authors.lastname: Cahill
authors.forename: D
authors.initials: D
authors.lastname: Burchette
authors.forename: M J
authors.initials: MJ
authors.lastname: Kerin
authors.forename: J L
authors.initials: JL
authors.lastname: Kelly
mesh_terms: D004282:Documentation / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D061646:Operative Time; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative; D058106:Wound Closure Techniques