Abstract
One FY1 doctor assessed 111 consecutive general surgical operative notes from 2010 along RCS guidelines. The authors determined that one-third of the notes were illegible or only partly legible. Of those, two-thirds contained abbreviations, 9% of which were not understood by the FY1. Alarmingly, 20% had no recorded postoperative instructions and the responsible consultant was only identifiable in 50% of the notes. After presenting the data to their audit meeting it was decided to switch to a typed operative note template system based on the RCS guidelines.
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