A prospective audit of the quality of documentation of gynaecological operations

Abstract

There is a paucity of audits in the speciality of Obstetrics and Gynaecology to estimate the standard of documentation of operation notes. Evidence from several audits across all specialities indicates the overall standard of reporting and documentation in medicine is poor, with many reports failing to contain important and pertinent data. Various attempts have been made to address these shortcomings. To estimate the degree of non-compliance in gynaecological practice, we set out to prospectively audit the standard of documentation of operation notes in a busy District General Hospital serving the largest Borough in terms of population in the city of London. An initial prospective audit was carried out in July 2008; and this was re-audited after 12 months using a standardised proforma based on the Royal College of Surgeons of England guidelines. There was evidence of significant improvement with the use of a standardised proforma.

Keywords::

• Audit
• documentation
• gynaecological surgery
• operation notes
• proforma

Acknowledgement

We would like to acknowledge the contribution of all Consultants in the Department of Obstetrics and Gynaecology at the Croydon University Hospital, for their participation in the Audit and their respective advice following the presentation of the audit outcome.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper