Is There Adequate Information on Operation Notes? the Application of the Royal College of Surgeons of England Guidelines

Abstract

An audit was performed to review the compliance and applicability of the Royal College of Surgeons of England (RCSEng) guidelines for operation notes in a regional plastic surgery department. 137 operation notes were initially audited revealing a variable quality when compared to the guidelines. An aide-memoire (Figure 1) was used to detail each of the ten guidelines and allowed the surgeon to record if any of the guidelines were not applicable. 151 operation notes were subsequently reviewed, and showed an improvement in the recording of the operative note and the varied applicability of the guidelines to this particular speciality. It is concluded that the RCSEng guidelines are not universally applicable to plastic surgery. The difference between ‘not applicable’ and ‘failure to record’ is potentially important if these guidelines are used by non-clinical audit staff in a target driven environment.