Please use this identifier to cite or link to this item: http://ahro.austin.org.au/austinjspui/handle/1/16949
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dc.contributor.authorNzenza, Tatenda C-
dc.contributor.authorManning, Todd-
dc.contributor.authorNgweso, Simeon-
dc.contributor.authorPerera, Marlon-
dc.contributor.authorSengupta, Shomik-
dc.contributor.authorBolton, Damien M-
dc.contributor.authorLawrentschuk, Nathan L-
dc.date2017-11-17-
dc.date.accessioned2017-11-21T01:12:20Z-
dc.date.available2017-11-21T01:12:20Z-
dc.date.issued2017-11-17-
dc.identifier.citationANZ Journal of Surgery 2017; online first: 17 Novemberen_US
dc.identifier.urihttp://ahro.austin.org.au/austinjspui/handle/1/16949-
dc.description.abstractBACKGROUND: Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met. METHOD: We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines. RESULTS: Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard. CONCLUSIONS: The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.en_US
dc.subjectGeneral surgeryen_US
dc.subjectOperation noteen_US
dc.subjectOperation reporten_US
dc.subjectUrologyen_US
dc.titleQuality of handwritten surgical operative notes from surgical trainees: a noteworthy issueen_US
dc.typeJournal Articleen_US
dc.identifier.journaltitleANZ Journal of Surgeryen_US
dc.identifier.pubmedurihttps://www.ncbi.nlm.nih.gov/pubmed/29148172en_US
dc.identifier.doi10.1111/ans.14239en_US
dc.description.affiliatesAustin Health, Heidelberg, Victoria, Australiaen_US
dc.type.contentTexten_US
dc.identifier.orcid0000-0002-1157-7003en_US
dc.identifier.orcid0000-0003-3357-1216en_US
dc.identifier.orcid0000-0001-8553-5618en_US
dc.identifier.orcid0000-0002-5145-6783en_US
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