An audit of orthopedic operation notes: what are we missing?

Abstract:

The importance of complete and legible operation notes is indisputable. Orthopedic operation notes at the author’s institution were audited against guidelines regarding content and legibility. Although of generally good standard it was found that in some cases important information was being missed and that a high proportion of notes had sections that were deemed illegible. A computerized proforma for writing notes has been proposed.

Keywords::

• orthopedic
• operation notes
• audit