NOTES - A SUITABLE CASE FOR AUDIT

The increasing emphasis on management responsibilities and audit led u s to investigate the state of surgical notes in our hospital. Twelve c riteria were evaluated regarding information that should be contained in the notes and the absence of this important information was documen ted. Deficiencies were revealed in all criteria selected. Until hospit al patients files are well kept and maintained, retrospective audit wh ether financial or medical will not be valid. A significant injection of resources is required to redress the situation. Hospitals which hav e not carried out detailed studies into the contents of their notes ne ed to do so as a matter of urgency.