Background The GMC's Good Medical Practice document advises that doctors should ‘keep clear, accurate and legible records.’1 Patient care, potential complaints and litigation may be hampered by illegible or incomplete documentation.
Aim To assess if basic documentation was being completed in operative delivery/postnatal surgery operative notes.
Method 50 postnatal case notes for the period January until May 2009, were randomly obtained from the discharge boxes of the Wishaw General Hospital. The following basic data were recorded within spreadsheet format: Whether the date, time, type of procedure, legible signature, grade and GMC or page number of the operating surgeon were documented.
Results 50 case notes were obtained of which 7 Consultants, 2 Staff Grades and 41 Registrars had completed operation notes. The date and time had been recorded in 82% and 46%, respectively. In 100% the type of procedure was documented. 68% contained a legible signature. None contained the surgeon's GMC number, but one did contain the surgeon's page number.
Conclusion Within our unit there was an inadequate level of documentation within the operative delivery and postnatal surgery operation notes. This information was disseminated at postgraduate teaching and will be re-audited.
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