Bateman N D, Carney A S, Gibbin K P
Department of Otolaryngology-Head & Neck Surgery, Queen's Medical Centre, Nottingham, UK.
J R Coll Surg Edinb. 1999 Apr;44(2):94-5.
Hand-written operation notes are often produced as evidence in medico-legal cases. Incomplete and illegible notes, along with the use of confusing abbreviations, are a common source of weakness in a surgeon's defence. An audit of 100 sets of operation notes was carried out in a single otolaryngology department. Notes were scrutinised for the accuracy of data, ward, department and name of surgeon, as well as for the inclusion of unacceptable abbreviations. Using an aide-memoire attached to the front of the operation sheet, the audit was repeated with identical criteria. The aide-memoire improved the standard of operation note with respect to all measured criteria. Clear identification of operating surgeon improved from 74% to 93%, and the avoidance of unacceptable abbreviations rose from 53% to 84%. We conclude that a simple aide-memoire attached to operation note sheets can significantly improve the quality of note-keeping and potentially avoid medico-legal problems.
手写手术记录常常作为医疗法律案件中的证据。不完整且难以辨认的记录，以及使用令人困惑的缩写，是外科医生辩护中的常见薄弱环节。在一个单一的耳鼻喉科部门对100套手术记录进行了审核。审核内容包括数据的准确性、病房、科室和外科医生姓名，以及是否包含不可接受的缩写。使用附在手术单正面的备忘单，按照相同标准重复审核。备忘单在所有测量标准方面提高了手术记录的质量。明确识别手术医生的比例从74%提高到了93%，避免使用不可接受缩写的比例从53%提高到了84%。我们得出结论，附在手术记录单上的简单备忘单可以显著提高记录保存质量，并有可能避免医疗法律问题。
