AN AUDIT OF OPERATIVE NOTES AT TUTH

Abstract

Objective:

To observe the completeness of the operative notes in the GMSMA of ENT and Head & Neck studies, TUTH, IOM with respect to the guidelines of RCS (Royal college of Surgeons) and compare the results with that of  previous  audit conducted in  July 2009.

Material and Methods:

Fourty eight operative notes were randomly analysed retrospectively for completeness and proper documentation as per the protocol laid down in Good Surgical Practice by the Royal College of Surgeons of England (RCS Eng), 2008.

Results:

All of the operative notes had date, pre-operative diagnosis, complete surgical procedure, per-operative findings, surgeon’s name, post-operative plan with author’s name and signature. 97% had inpatient number, 93% had bed number and 89.5% had post-operative diagnosis.

Conclusion:

Regular audit should be done to improve the standard of operative notes that must be legible and complete to be produced as evidence in the court. Digital system is better than manual one for the documentation.

Keywords: audit, evidence, operative notes