An audit of the quality of operation notes in an otolaryngology unit

J R Coll Surg Edinb. 1999 Apr;44(2):94-5.

Abstract

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.

MeSH terms

  • Benchmarking
  • Humans
  • Liability, Legal*
  • Malpractice
  • Medical Audit*
  • Medical Records / standards*
  • Otolaryngology / standards*
  • Otorhinolaryngologic Surgical Procedures / statistics & numerical data*
  • Quality Control
  • Writing / standards