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1.3 Record your work clearly, accurately and legibly

Further resources in this section

Surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained of all their interactions with patients. In meeting the standards of Good Medical Practice you should:

  • Be fully versed in the use of the electronic health record system used in your organisation and record clinical information in a way that can be shared with colleagues and patients and reused safely in an electronic environment.
  • Take part in the mandatory training on information governance offered by your organisation, including training on data protection and access to health records.
  • Ensure that all medical records are accurate, clear, legible, comprehensive and contemporaneous and have the patient’s identification details on them.
  • Ensure that when members of the surgical team make casenote entries these are legibly signed and show the date, and, in cases where the clinical condition is changing, the correct time.
  • Ensure that a record is made of the name of the most senior surgeon seeing the patient at each postoperative visit.
  • Ensure that a record is made by a member of the surgical team of important events and communications with the patient or supporter (for example, prognosis or potential complication). Any change in the treatment plan should be recorded.
  • Ensure that there are clear (preferably typed) operative notes for every procedure. The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. The notes should include:
    • Date and time
    • Elective/emergency procedure
    • Names of the operating surgeon and assistant
    • Name of the theatre anaesthetist
    • Operative procedure carried out
    • Incision
    • Operative diagnosis
    • Operative findings
    • Any problems/complications
    • Any extra procedure performed and the reason why it was performed
    • Details of tissue removed, added or altered
    • Identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials
    • Details of closure technique
    • Anticipated blood loss
    • Antibiotic prophylaxis (where applicable)
    • DVT prophylaxis (where applicable)
    • Detailed postoperative care instructions
    • Signature 
  • Ensure that sufficiently detailed follow-up notes and discharge summaries are completed to allow another doctor to assess the care of the patient at any time
  • Ensure that you are familiar and fully compliant with the guidelines of the Data Protection Act 1998 around the use and storage of all patient identifiable information.
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Domain 2 – Safety and Quality »

 

Resources

Title/Links Author Published Date
Standards for the clinical structure and content of patient records RCS and Health and Social Care Information Centre
2013
Data Protection Act Gov
1998
Guidelines for Clinicians on Medical Records and Notes RCS 1994
Confidentiality GMC 2009
Medical Records Medical Protection Society 2013
Good Record Keeping
Medical Defence Union

                                   

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