Notes: a suitable case for audit. Issue 813 (July 1993)

• Record Type: Journal Article
• Authors: Twigg, J.; Briggs, T.; Parker, C.; Miller, R.
• Is Part Of: Postgraduate medical journal. Volume 69:Issue 813(1993)
• Page Start: 578
• Page End: 580
• Publication Date: 1993-07
• Subjects: Medicine -- Periodicals; 610
• DOI: 10.1136/pgmj.69.813.578
• Languages: English
• ISSNs: 0032-5473

Abstract

Abstract : The increasing emphasis on management responsibilities and audit led us to investigate the state of surgical notes in our hospital. Twelve criteria were evaluated regarding information that should be contained in the notes and the absence of this important information was documented. Deficiencies were revealed in all criteria selected. Until hospital patients files are well kept and maintained, retrospective audit whether financial or medical will not be valid. A significant injection of resources is required to redress the situation. Hospitals which have not carried out detailed studies into the contents of their notes need to do so as a matter of urgency.