The Quality of Operative Notes at a General Surgery Unit
practice, accurate documentation is critical. This is particularly true for operative procedures, and medical councils have identified this and published guidelines to aid
surgeons. However, these remain a frequently cited weakness in their defence in medico-legal cases. This study assessed the accuracy of operative notes in a general surgery unit in order to improve our practice.
Method. An audit of 100 consecutive operative notes was performed, and notes were assessed using the Royal College of Surgeons guidelines. The quality of note-taking of trainees was compared with that of consultant surgeons. A series of operation note pro formas was designed in response to the findings.
Results. Of the notes, 66% were completed by trainees. The vast majority of notes had no diagram to demonstrate the surgical findings or illustrate the actions. Specialist surgeons
were more likely to describe the actions accurately, but less likely to describe wound closure methods or dressings used. They were also less likely to complete adequate postoperative
Conclusions. This study identifies key areas of weakness in our operative note-keeping. Pro formas should be introduced and made available for commonly performed procedures, and
diagrams should be used wherever possible.
South African Medical Journal Vol. 98 (9) 2008: pp. 726-728