Hand-written operation notes are often produced as evidence in medico-legal
cases. Incomplete and illegible notes, along with the use of confusing abb
reviations, are a common source of weakness in a surgeon's defence. An audi
t of 100 sets of operation notes was carried out in a single otolaryngology
department. Notes were scrutinised for the accuracy of data, ward, departm
ent and name of surgeon, as well as for the inclusion of unacceptable abbre
viations. Using an aide-memoire attached to the front of the operation shee
t, the audit was repeated with identical criteria. The aide-memoire improve
d the standard of operation note with respect to all measured criteria. Cle
ar 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 significan
tly improve the quality of note-keeping and potentially avoid medico-legal
problems.