An audit of the quality of operation notes in two district general hospitals. Are we following Royal College guidelines?

The quality of medical record keeping is being subjected to increasingly close scrutiny. The 1992 report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) noted a considerable variation in the quality of operation notes submitted by all contributing surgical specialties. This study has audited the quality of 264 general surgical operation notes written by 10 consultants and 16 trainees in two district general hospitals (DGH). Postoperative instructions were absent in nearly two-thirds of operation notes and serial numbers of prostheses were rarely recorded. On almost every criterion trainees scored higher than consultants and emergency operation notes scored better than elective notes. About 70 per cent of notes written by consultants were illegible or the procedure could not be understood from the description given, by the nurse or junior doctor collecting the data. Until word processor databases become more widespread in operating theatres, it is suggested that a specifically designed proforma be used, with prescribed headings to act as aides-mémoire for the surgeon.