Audit of surgical operation notes in a teaching hospital, south western Nigeria: based on royal college of surgeons of England as standard

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Author: 
Akanbi Olusola Olateju, Adeoti Moses Layi, Oguntola Adetunji Saliu, Onilede David Adekunle, Aderounmu Adebimpe O. Atilola and Olawale Lateef Idris
Abstract: 

Operation notes are important medical records that document operative procedures, intra operative findings, subsequent care and plan for the patients. The value of quality operation notes for academic, research, clinical auditing and when medical litigation arises cannot be disputed. These notes when properly documented will help to promote prompt response to care and need of patients in post operative period. This study assess the quality of operation notes in our centre by reviewing all the available operation notes over a 2 year period retrospectively against a set standard by Royal College of Surgeons of England. Our study revealed deficit in some areas of information with good compliance in other areas. We therefore recommend the use of standard operation note based proforma as aide-memoires, will help improve the quality of our operation notes.

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   Vol. 07, Issue 03, March 2017

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