Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

Abstract

Background: Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met. Method: We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors a..