Nighat Bakhtiar, Abdul Khalique, Foad Ali Moosa, Masood Jawaid.
Are we achieving the bench mark of surgical clinical case notes at Dow University Hospital?.
Pak J Surg Jan ;28(4):243-6.

Objective: To fi nd out quality of surgical case notes according to standard guidelines of Royal College of Surgeons England. Study Design: Clinical Audit Place and Duration of Study: Department of Surgery, Dow University Hospital from February 2012 to April 2012. Methods: Medical records of all patients admitt ed in surgery department of Dow University Hospital were reviewed according to Royal College of Surgeons Of England guideline which covers main areas of clinical case notes including patient’s identifi cation data, verifi cation, clinical content, data in operative sheets and investigations. None of the doctor was aware that case notes were being audited. Results: A total 238 case notes were reviewed with 80% of standard achieved in 23 of 35 standards. In identifi cation and demographic data, date of case notes was mentioned in 205(86.1%) fi les, while in only 2 (1%) notes, time and designation of doctor was writt en. In clinical content record, actual diagnosis was mentioned in 230 (96.6%) cases and 10 (4.2%) of entries type of admission was mentioned. Handwriting was legible in 213 (85.3%) notes. In operation sheet record, type of operation was mentioned in 224(94.1%) of entries but only 96 (40.3%) had hospital registration number writt en. Consent form was present and signed in 232 (97%). Not a single investigation was signed or initialed. Conclusion: Th e case notes in surgical department at Dow University Hospital are not up to mark with respect to case notes standard of Royal college guidelines .Th e most important neglected areas are hospital registration number on every page and signature at investigations and radiology reports.

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