Visits: 119
A common practice increasingly alarming for the surgeons is insufficient and inadequate case notes, follow-up, operation notes, discharge notes etc. which bothers the duty doctors in follow up time or in post-operative period and other surgeons during future visits for incompleteness. For better practice regarding record keeping the following should be kept in mind carefully:
Ensure-
- All medical records are legible, complete and contemporaneous, and have the patient’s identification details on them.
- That when members of the surgical team make case-note entries they are legibly signed and show the date, and, in cases where the clinical condition is changing, the correct time.
- That a record is made of the name of the most senior surgeon seeing the patient at each post-operative visit.
- That a record is made by a member of the surgical team of important events and communications with the patient or supporter (for example, prognosis or potential complication). Any change in the treatment plan should be recorded.
- That there are legible operative notes (typed if possible) for every operative procedure. The notes should accompany the patient into recovery and to the ward and should be insufficient detail to enable continuity of care by another doctor. The notes should include:
- Date and time;
- Elective/emergency procedure;
- The names of the operating surgeon and assistant;
- The operative procedure carried out;
- The incision;
- The operative diagnosis;
- The operative findings;
- Any problems/complications;
- Any extra procedure performed and the reason why it was performed;
- Details of tissue removed, added or altered;
- Identification of any prosthesis used, including the serial numbers of prosthesis and other implanted materials;
- Details of closure technique;
- Post-operative care instructions; and
- A signature.
- Ensure that follow-up notes are sufficiently detailed to allow another doctor to assess the care of the patient at any time.
(Collected from internet)