An Opportunity in Op-Notes. Issue 10 (October 2015)

• Record Type: Journal Article
• Authors: Rudra, S; Kieffer, Wkm; Briffa, N; Kantak, A
• Is Part Of: Journal of perioperative practice. Volume 25:Issue 10(2015)
• Page Start: 204
• Page End: 206
• Publication Date: 2015-10
• Subjects: Trauma -- Orthopaedics -- Record-keeping -- Theatres; Operating room nursing -- Periodicals; 617.9192
• DOI: 10.1177/175045891502501004
• Languages: English
• ISSNs: 2515-7949

Abstract

Operative notes in surgical practice are a vital source of information and communication between healthcare professionals as well as being a legal document. Errors and omissions can have serious effects on patient care and lead to confusion. We audited our compliance within trauma and orthopaedics at a busy district general hospital in South East England with the standard set by the Royal College of Surgeons (England) before and after the introduction of an operation note template. We achieved significant improvements in compliance across almost all of the standard's domains and recommend widespread implementation of similar templates nationally.