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Reaudit on documentation in operative deliveries
  1. R Rajagopal,
  2. R Lindsay,
  3. M Oak,
  4. G Ofili
  1. Wishaw General Hospital, Lanarkshire, UK

Abstract

Background Good medical practice by GMC states that good records are part of good management. These records should be clear, accurate and legible with adequate information.

Aim To reaudit the basic documentation by middle grades and consultants in operative deliveries.

Materials and method Case notes awaiting discharge letters were randomly obtained for the study between January 2010 and April 2010. Data on documentation under the headings date, time, type of the procedure, indication, legible signature, GMC number and adequacy was collected.

Results 100 case notes were analysed. Documentation in 77 were by registrars, 9 by staff grades, 6 by consultants and 8 were by both registrars and consultants. The operative delivery was caesarean section in 72 cases and instrumental delivery in 28 cases. Documentation of date of operation was 86% (vs 82% in previous audit)time 68% (vs 46%) and type of operation and indication was 100% (vs 100%). It had a legible signature in 81% (vs 68%) and GMC number was documented only in 27% of cases (vs 0% in previous audit). Documentation by registrars was found to be adequate in 78%and by consultants in 61%.

Conclusion It is heartening to note good improvement in documentation in this reaudit. Documentation by middlegrades was better than consultants. However it is still not adequate and has huge implications in the litigation process. Surgeons have been made aware of the results of this reaudit and have been asked to comply with the recommendations of the GMC.

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