Third prize winner at Dow Annual Faculty Research Day 2013

1. Are we achieving the bench mark
of surgical clinical case notes at
Dow University Hospital?
Nighat Bakhtiar, Abdul Khalique, Foad Ali Moosa, Masood Jawaid
Dr. Masood Jawaid
Assistant Professor Surgery
Dow International Medical College

4. Continuation of care
Audit

5. If it’s not written,
It did not happen!!

8. Objective
• To find out quality of surgical case
notes according to standard
guidelines of Royal College of
Surgeons England

9. Methods
• Study Design: Clinical Audit
• Setting: Surgery, Dow University Hospital
• Duration: February 2012 to April 2012.
• Inclusion: All patients records during the
study period
• Sample size: 238 case notes

10. Guideline
Royal College of
Surgeons Of England
35 standards
Main areas covered
• Patient’s identification data
• Clinical content
• Data in operative sheets
• Investigation
Osbron GD, Pike H , Smith M, Winter R, Vaughan-Williams E.
Quality of clinical case notes entries: How good are we achieving set standards? Ann
R Coll Surg Engl. 2005; 87(6): 458–460

11. Identification data n %
Patient name on every page 75 31.5
Patient Registration # on every page 5 2.1
Every entry should be dated 205 86.1
Every entry should be timed 2 0.8
Every entry should be signed 198 83.2
Every note should have clinician’s name 8 3.4
Clinician’s designation 2 0.8
There must be an entry each weekday 211 88.7

12. Clinical Content n %
Type of admission 10 4.2
Presenting compliant 213 89.5
History of presenting compliant 207 87.0
Previous medical history 204 85.7
Family history 198 83.2
Details of initial examination 187 78.6
Working diagnosis 226 95.0
Plan of treatment/investigations 84 35.3
Was an actual diagnosis documented 230 96.6

13. Operative Notes n %
Patients name 196 82.4
Hospital registration number 96 40.3
Date of birth 147 61.8
Date of operation 203 85.3
Surgeon’s name 220 92.4
Anesthetist’s name 194 81.5
Technician’s name 158 66.4
Type of operation 224 94.1
Consent form 232 97.5
Consent form signed 232 97.5

14. Investigations n %
Are all test results
0 0
signed/initialed
Are all X-ray test results
0 0
signed/initialed

18. Thank you