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Operative Notes (operative + note)

Distribution by Scientific Domains

Medical Sciences	100%

Selected Abstracts

AN AUDIT OF OPERATIVE NOTES: FACTS AND WAYS TO IMPROVE,

ANZ JOURNAL OF SURGERY, Issue 9 2008
Liviu P. Lefter
Background: Accurate operation record keeping is an important element of risk management. Handwritten surgical notes are often produced as evidence in medico-legal malpractice cases and incomplete and illegible notes may be a source of weakness in a surgeon's defence. Therefore, we audited the surgical notes in a teaching hospital surgical department. Methods: During 1 week 190 operative notes were audited for patient identity details, preoperative diagnosis, operation title and details, CMB code, postoperative instruction and author of the note. The operative notes were assessed by a medico-legal lawyer and a medical expert to establish level of legibility and usefulness in a virtual court case. Results: Several operative notes were found incomplete (51.57%) missing important information as CMB code (13.68%), patient details (6.8%) preoperative diagnosis (6.31%), operation title (6.31%) and postoperative instruction (14.73%). Overall, only 92 notes were complete. Conclusion: This audit suggests that handwritten surgical notes generate several errors that could lead to confusion when notes are reviewed for further follow up or are produced as evidence in medico-legal disputes. [source]

Correlation of Findings on Direct Laryngoscopy and Bronchoscopy With Presence of Extraesophageal Reflux Disease

THE LARYNGOSCOPE, Issue 9 2000
Michele M. Carr DDS
Abstract Objective To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD). Study Design Retrospective chart review Methods Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy). Results A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality. Conclusion Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis. [source]