Sameeah Hanif, Muhammad Nawaz.
An audit of operating notes in a general surgical unit: findings and how to improve for patient well being.
Pak J Surg Jan ;38(1):22-5.

Introduction: The value of comprehensible and complete operative notes cannot be denied. Up to mark operative notes will result in smooth and consistent transfer of right information from operation theater to recovery room and beyond. Objective: To retrospectively evaluate surgical hand written operative notes with established guidelines of Royal College of Surgeons (RCS) of England. Material and Methods: This retrospective (cross sectional) audit was carried out in Department of Surgery, DHQ, Abbottabad, from 1st June to 31st July 2021. A sample of 60 operatives notes were selected randomly for audit. Operative notes were assessed according to guidelines laid by Royal College of Surgeons (RCS) of England (Good surgical practice). Results: Out of 60 operative notes in 57(95%) date was written, operative time was mentioned in 52(86.7%), none of the operative notes had shown the kind of surgery (emergency/elective), name of operating surge1on, assistant, name of operative procedure, findings, operative diagnosis, detail of tissue added, removed or altered, post-operative instruction was mentioned in all 60 note (100%). Conclusion: Operative notes have a vital role in patient`s management audit should be a done regularly to improve the standard of operation notes. They must be legible and complete to avoid litigation. Apart from that several errors can occur in hand written operation notes; going through them for any purpose is cumbersome.

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