Abstract
Background: An accurate, complete, legible medical record implies accurate, complete organized assessment and management of the patient. Operation notes as one of the important patient’smedical records are often produced as evidence in medico-legal cases. In a court of law, that which is not written down may be perceived as never having occurred. Poorly written and illegible notes, along with the use of confusing abbreviations, are a common source of weakness in a surgeon'sdefense.Objectives: This audit was carried out mainly to assess and review the compliance and adhere of surgeon to existing operation guidelines sheet of ministry of health (form 15), and to enhance professionalism.Methodology: In this retrospective audit, 266 operation notes were reviewed in general surgical department of King Faisal Hospital, Makkah, Kingdom of Saudi Arabia, during a period of six months (January - June 2007). Because we have no standing ethical committee in our hospital theapproval and permission were given by the administration for this study. Notes were scrutinized and reviewed for the quality, accuracy of patient’s personal data, details of operation and name of surgeon, operating team, details of operation, swabs, instruments counts, as well as for the inclusionof unacceptable abbreviations. The standard operation sheet (form 15) guideline of Ministry of Health, Kingdom of Saudi Arabia, attached to the patient’s file was used as a reference.Results: None of the notes were completely filled in this audit, some of important vital data of patients e.g. identification data were missed in (122 patients 45.9 %), and usage of non standardized abbreviations was found in 118 (44.4%). The types of the operation (emergency/elective) wasrecorded in 179 (67.3%) of all the operative notes. The time of the operation was recorded in 129 (48.5%) of the operative notes. Wound closure details were recorded in 153 (57.5%) of the notes and many other data like name of surgeon, anesthesiologists, type of anesthesia were variably missed.Conclusion: We conclude that a simple compliance to the attached operation note sheets can significantly improve the quality of the notes, continuity of care and potentially avoid medico-legal problems. There is an urgent need for revision and modification of form No: 15 operation sheet of Ministry of Health as well as introduction of computer database in operation notes. This should be an issue for the Faculty of Medicine, making the training of future surgeons more effective.
Highlights
An accurate, complete, legible medical record implies accurate, complete organized assessment and management of the patient
A retrospective audit survey was carried out to trace all the written operation notes by all grades of the department of surgery at King Faisal Hospital, Makkah, Saudi Arabia, over a period of 6 months (January –June 2007). This audit comprised all elective and emergency operations .The operation notes were assessed and reviewed by two members of the surgical team and graded in a quantitative scale for the compliance and completion of the items stated in the guidelines of the operation sheet stipulated by the Ministry of Health Fig 1, with regard to the following: patient’s identifications, date and time of surgery, it includes the type of surgery, narrative description and details of procedure, the final diagnosis type of closure and surgeon’s signature
Accurate medical record keeping is an important skill that should be mastered by all physicians
Summary
Compliance of surgeons care, planning future operative procedures, research projects, quality assurance, billing, and medical-legal conflicts. METHODOLOGY: A retrospective audit survey was carried out to trace all the written operation notes by all grades of the department of surgery at King Faisal Hospital, Makkah, Saudi Arabia, over a period of 6 months (January –June 2007) This audit comprised all elective and emergency operations .The operation notes were assessed and reviewed by two members of the surgical team (one specialist and one consultant) and graded in a quantitative scale for the compliance and completion of the items stated in the guidelines of the operation sheet stipulated by the Ministry of Health (form 15) Fig 1, with regard to the following: patient’s identifications, date and time of surgery, it includes the type of surgery, narrative description and details of procedure, the final diagnosis type of closure and surgeon’s signature. It was determined that an intervention was required to improve the quality of the operative note data set
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