An Audit of Orthopaedic Operative Notes : Do we Need Improvement?

Abstract

Accurate and detailed operation notes are of great importance in all surgical specialties not only for safe patient care but also for providing information for research, audit, and medico legal purposes. Thus, importance of complete and legible operation notes is indisputable. Orthopaedic operation notes at the Government Medical College, Amritsar were audited against guidelines regarding content and legibility. Although of generally good standard it was found that in some cases important information was being missed and that a high proportion of notes had sections that were deemed illegible. A computerized pro forma for writing notes has been proposed. Also. It has been proposed that all the Resident Doctors of Department should undergo training for writing notes and Aide Memoires be placed throughout the OT Complex.

Keywords: orthopaedic, operation notes, audit.