Qurrat Al Ain Atif.
An audit of operative notes in general surgery at Pakistan Institute of Medical Sciences (P.I.M.S.), Pakistan. Do we follow the Royal College of Surgeons (England) guidelines?.
J Pak Med Assoc Jan ;70(3):491-3.

To evaluate operative notes in the light of a standard guideline, and to establish a new more precise proforma for future documentation. The retrospective study was conducted at the Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and comprised audit of consecutive General Surgery elective operation theatre notes from October 2015 to November 2015 according to Royal College of Surgeons (England) guidelines 2014. After the audit, all the doctors were educated about the completion of operation notes and an experimental operation notes template was designed and implemented. Re-audit was done. A total of 60 operation notes were audited, and of the 20 parameters in the checklist, only 2(10%) were filled up at all times; surgeon's name and procedure. In the remaining 18(90%) parameters, the value ranged from 0% to 98.3%. Re-audit showed 100% note-taking across all the 20 parameters. The new proforma for operative notes allowed no room for error or missed entries.

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