Authors: Osborn, G.D.; Pike, H.; Smith, M.; Winter, R.; Vaughan-Williams, E.

Source: Annals of The Royal College of Surgeons of England, Volume 87, Number 6, November 2005 , pp. 458-460(3)

Publisher: The Royal College of Surgeons of England

Abstract:

Introduction: High quality entries in case notes are becoming increasingly important. Standards exist on what information entries should contain. We have compared case notes from surgical teams at the Royal Glamorgan Hospital with standards based on guidelines from The Royal College of Surgeons of England.

Patients and Methods: A total of 120 case notes, randomly selected from the department of general surgery, were reviewed.

Results: An 80% compliance was achieved in 25/35 standards and 100% was achieved in 6 (patient's name, date, surgeon's name and type of operation on the operation sheet and consent form signed and dated). The following fell short of 80% compliance: PAS number on every page (75%); entries timed (27%); and clinician's name (16%) and designation (27%) printed. Social history was only recorded in 73% of clerkings and family history in 33%. Results of laboratory tests were signed in 65% of notes and radiological tests were signed in 41%.

Conclusions: Healthcare professionals need to be aware of, and comply with, standards. House officers should be given information about standards at departmental induction or during medical training.

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Keywords: CASE NOTES; QUALITY; AUDIT

Document Type: Research article

DOI: http://dx.doi.org/10.1308/003588405X60632

Affiliations: 1: Department of General Surgery, Royal Glamorgan Hospital, Llantrisant, UK

Publication date: 2005-11-01

More about this publication?

• The Annals of The Royal College of Surgeons of England is the official journal of the College and is published eight times a year in January, March, April, May, July, September, October and November. The main aim of the journal is to publish high quality, peer-reviewed papers that relate to all branches of surgery.
  
  The Annals also includes letters and comments, a regular technical section, NICE news, controversial topics, CORESS feedback, book reviews and the best trainee presentations from England and Wales. The editorial board is composed of members of the College Council and experts from across the surgical specialties.
  
  Archive issues of the Annals of The Royal College of Surgeons of England are available via the PubMed Central database
  
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