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.

[1]  A. Carney,et al.  An audit of the quality of operation notes in an otolaryngology unit. , 1999, Journal of the Royal College of Surgeons of Edinburgh.

[2]  Brian J Smith,et al.  Operative Note Dictation: Should It Be Taught Routinely in Residency Programs? , 2004, Obstetrics and gynecology.

[3]  A O'Bichere,et al.  The quality of operation notes: can simple word processors help? , 1997, Annals of the Royal College of Surgeons of England.

[4]  Michael B Flynn,et al.  The operative note as billing documentation: a preliminary report. , 2004, The American surgeon.

[5]  R. Moore.  The dictated operative note: important but is it being taught? , 2000, Journal of the American College of Surgeons.