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    Standards in operation notes is it time to re-emphasise their importance?

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    Article8386.pdf
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    Authors
    Cahill, KC
    Issue Date
    2016-01
    Keywords
    GUIDELINE
    SURGERY
    Local subject classification
    MEDICAL NOTE TAKING
    
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    Show full item record
    Publisher
    Irish Medical Journal
    Journal
    Irish Medical Journal
    URI
    http://hdl.handle.net/10147/597132
    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 â 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, surgeonâ 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.
    Item Type
    Article
    Language
    en
    Collections
    Galway University Hospitals

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