An audit of the quality of operation notes in an otolaryngology unit

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.