scholarly journals 683 Minimum Data Set in Documentation of Operative Findings in Diagnostic Laparoscopy

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
S Nakhuda ◽  
A Liyanage ◽  
R Satchidanand
Keyword(s):  
General Medical Council ◽  
Second Phase ◽  
Medical Council ◽  
Data Set ◽  
Record Keeping ◽  
Operative Note ◽  
Quality Of Patient Care ◽  
Operative Findings ◽  
Operative Notes

Abstract Aim Legible, accurate and clear documentation of operative findings is an integral part of patient safety, with guidelines from the Royal College of Surgeons and General Medical Council having clear standards of operative note-keeping. However, a substantial variation in the quality and accuracy of these notes can still be observed in everyday practice. We recognised the significance of a minimum set of data in operative record keeping for diagnostic laparoscopies as a standard, to improve quality and uniformity. Method We retrospectively examined 50 diagnostic laparoscopies over 6 months and assessed their operative notes against the guidelines described above. We found that there was no clear uniformity in reporting, subjective descriptions used and a significant amount of under-reporting of operative findings. We developed a proforma as a substitute for the documentation of operative findings which was implemented in the second phase of the audit and the compliance was assessed over a 3-month period. Results We found that usage of the proforma was limited (9/22), however those notes using the proforma were compliant with the guidelines for operative note keeping, to a much higher degree than those without. All the operative findings were documented for 100% of those notes which used the proforma; for those using freehand notes, only the appendix was identified to the same standard, which is explained by all diagnostic laparoscopies proceeding to appendicectomies. Conclusions Using a proforma as standard record keeping can improve the quality and accuracy of operative notes and thereby help improve safety and quality of patient care.

scholarly journals Improving standards in clinical record-keeping

2006 ◽  
Vol 12 (4) ◽  
pp. 280-286 ◽  
Author(s):  
Ian Pullen ◽  
John Loudon
Keyword(s):  
Clinical Care ◽  
Good Practice ◽  
General Medical Council ◽  
Medical Council ◽  
Record Keeping ◽  
Fit For Purpose ◽  
Clinical Tools ◽  
Reasons For Decisions ◽  
Clinical Records

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. Essential for effective communication and good clinical care, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health ombudsmen's reports and the courts have repeatedly criticised the quality of records and the resulting failings of care. Most advice from professional bodies, indemnity organisations and the General Medical Council is extremely brief and confined to individual entries in the record. Patient safety and the demands of clinical governance make change essential. This article draws together standards and concludes with some good practice points for a fit-for-purpose, structured, multidisciplinary record to support good care and protect the interests of patients and clinicians. These principles should be equally applicable to electronic records.

Principles and Standards of Anaesthetic Monitoring

2011 ◽  
Author(s):  
Patrick Magee ◽  
Mark Tooley
Keyword(s):  
General Medical Council ◽  
International Standards ◽  
World Federation ◽  
Medical Council ◽  
The World ◽  
Minimum Requirements ◽  
Principles And Standards ◽  
Human Failure ◽  
Training Programmes

The World Federation of Societies of Anaesthesiology (WFSA) adopted standards relating to the safe practice of anaesthesia in 1992 and such standards had already been proposed by a number of countries in order to cut the morbidity due to anaesthesia itself. In the modern era it is easy to forget that historically anaesthesia and surgery did indeed have associated morbidity and mortality and there was very little assistance from technology to monitor patients. The evolution of these standards is based on two main requirements of monitoring. The first is to record anticipated deviations from normal values, which require accurate measurement to ensure patient safety. The second is to warn of unexpected, life-threatening events that, by definition, occur without warning, and could affect the fit, young patient as easily as the old and infirm. All international standards stress the importance of the continual presence of a fully trained and accredited anaesthetic person, and one Australian study demonstrated that many mishaps occur in the absence of such a person [Runciman 1988]. This applies to general and regional anaesthesia, sedation and recovery. Because perceptions of safety and standards vary throughout the world, despite the presence of an International Standards Organisation, debate about the minimum requirements for monitoring continue. Central to the maintenance of these standards is the quality of persons entering the specialty, the quality of training programmes, and the continuing education of specialists throughout a professional lifetime [Sykes 1992]. It is difficult to determine with certainty the effect that additional technological monitoring has on safety. One clear example is the inability of the trained human eye to detect cyanosis, this human failure occurring maximally at 81–85% oxygen saturation. Clearly, the pulse oximeter has improved the quality of cyanosis detection. Numerous studies all over the world have shown that mortality due to anaesthesia itself fell significantly between the 1950s and the 1980s, by which time extensive technological monitoring was being introduced, and training programmes had been very much improved. Utting [1987] reviewed 750 cases of death and cerebral damage reported to the British General Medical Council between 1970 and 1982 that were thought to be the result of errors in technique.

Patient Access to Medical Information

1988 ◽  
Vol 18 (1) ◽  
pp. 11-14 ◽  
Author(s):  
Johanna I. Westbrook
Keyword(s):  
Medical Information ◽  
Patient Access ◽  
Medical Practitioners ◽  
Record Keeping ◽  
Positive Effects ◽  
Quality Of Patient Care ◽  
Health Practitioners ◽  
Research Findings ◽  
Harmful Effects

This paper is the first of a 2-part article. In it, the author discusses issues relevant to patient access to medical records. Research findings suggest that the fear of many health practitioners regarding the harmful effects of such access are unjustified. Access to medical information improves patient-doctor relations, increases patient knowledge and compliance, has positive effects on patients' health, and improves the quality of record keeping. Other suggested advantages are increases in the quality of patient care and health practitioners' work satisfaction, and a decrease in malpractice suits. The hypotheses to be tested in a survey of medical practitioners' attitudes to these issues are discussed.

scholarly journals Addressing uncertainties about the effects of treatments offered to NHS patients: whose responsibility?

2007 ◽  
Vol 100 (10) ◽  
pp. 440-441 ◽  
Author(s):  
Iain Chalmers
Keyword(s):  
Patient Safety ◽  
General Medical Council ◽  
Medical Council ◽  
Promote Patient Safety

‘You must work with colleagues and patients to maintain and improve the quality of your work and promote patient safety. In particular you must … help to resolve uncertainties about the effects of treatments.’ General Medical Council 1

scholarly journals A Historical Look at the Indian Healthcare Professionals in the NHS

2019 ◽  
Vol 12 (1) ◽  
pp. 19-21
Author(s):  
Balmukind Bhala ◽  
Aruna Bhala ◽  
Neeraj Bhala
Keyword(s):  
Medical Education ◽  
Medical Service ◽  
Indian Subcontinent ◽  
General Medical Council ◽  
Healthcare Sector ◽  
Medical Council ◽  
Indian Medical ◽  
The Government ◽  
The Uk

Doctors and nurses from the Indian subcontinent have been working in the UK healthcare sector for over a 100 years. Initially only open to Europeans, Indians were allowed to enter the Indian Medical Service (IMS) in 1855, although the requisite was that they had to sit exams based in London and had to be registered with the General Medical Council (GMC). At the time there were many schools training Indian doctors, but only as licentiates. In relation to medical education, through pressure applied by the IMS, indigenous courses for the training of Indian doctors were abolished and several medical colleges, modelled along western pedagogic styles, were established. The staff of all these colleges were appointed from the IMS and their methods of instruction were virtually indistinguishable from those practised in England and Scotland. Indian degrees were recognised in 1892 by the GMC and this recognition persisted until 1975, with a short interlude in the mid-1930s when there was a dispute between the GMC and the Government of India about the quality of Indian medical education. 1

scholarly journals 1469 Audit of Clinical Notes Filing in Vascular Surgery

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M Griffiths ◽  
A Perusseau-Lambert ◽  
A Bush ◽  
D Mittapalli
Keyword(s):  
Vascular Surgery ◽  
Medical Practice ◽  
Royal College ◽  
Quality Care ◽  
General Medical Council ◽  
Medical Council ◽  
Chronological Order ◽  
Record Keeping ◽  
Clinical Notes ◽  
Good Medical Practice

Abstract Aim Assess the correctness of patient's notes filing following the Royal College of Physicians, Record Keeping Standards, and the General Medical Council, Good Medical Practice, guidance: medical notes must be filed in the correct section, in a chronological order, three key identifiers on each page. Method Over 3 months, the general surgical wards, using case notes and those using folders for the current admission were assessed to identify loose notes. The vascular surgery patients’ notes were reviewed for the following criteria: not loose, filed in the correct section, in chronological order, and had three key identifiers. Results Surgical wards using case notes had 28.6% of the notes filed (n = 21) compared with 78.9% filed on wards with admission folders (n = 57). Within vascular surgery (n = 15), 13.3% had all notes filed, 20% were in chronological order, 6.7% had notes filed in the correct section, and 20% had key identifiers on every page. Conclusions The filing of case notes on the vascular ward resulted in loose notes more than other wards that use admission folders. To resolve this, “Admission Folders” were introduced (alongside full case notes) to assist with filing and label sheets used to assist with fast identification of current admission documents. After implementation of Admission Folders, the staff found notes easier to access and follow, according to the staff surveys, and notes were correctly filed and given identifiers, ensuring continued quality care for the patients.

scholarly journals Clinical standards and the wider quality agenda

2000 ◽  
Vol 24 (3) ◽  
pp. 85-89 ◽  
Author(s):  
Paul Lelliott
Keyword(s):  
Medical Practice ◽  
General Public ◽  
Self Regulation ◽  
General Medical Council ◽  
Medical Council ◽  
Medical Practitioners ◽  
Professional Self ◽  
The Media ◽  
The Government

There is an unprecedented level of interest among the general public, the media and politicians in the quality of treatment and care provided by the NHS. Traditional methods for upholding the quality of medical practice, through professional self-regulation, are under attack. The General Medical Council (GMC) has responded by voting to introduce a process of revalidation for medical practitioners. If this is not seen to succeed, the Government could take this responsibility away from the GMC, and the Medical Colleges and Faculties.

scholarly journals The urological foot soldier: are we equipping our foundation-year doctors?

2010 ◽  
Vol 92 (8) ◽  
pp. 284-287 ◽  
Author(s):  
RJ Cetti ◽  
R Singh ◽  
L Bissell ◽  
R Shaw
Keyword(s):  
General Medical Council ◽  
Medical Schools ◽  
Undergraduate Teaching ◽  
Medical Council ◽  
Male And Female ◽  
Minimum Standards ◽  
Urethral Catheterisation ◽  
Therapeutic Procedures ◽  
Constant Feature

Tomorrow's Doctors was first published by the General Medical Council (GMC) in 1993. The recommendations provide a framework for UK medical schools to use to design detailed curricula and schemes of assessment in the training of future doctors. They also set out the minimum standards that are used to judge the quality of undergraduate teaching. In 2003 this guidance was revised and a further 2009 version has now been published. A constant feature of these important documents is a list of therapeutic procedures that all graduates are expected be able to perform safely and effectively. These include male and female urethral catheterisation.

Effectiveness of Audit and Feedback in Improving the Quality of Operative Notes - A Retrospective Observational Study

2019 ◽  
Vol 41 (1) ◽  
pp. 75-78
Author(s):  
Leison Maharjan ◽  
Aditya Singhal ◽  
Rajendra P S Guragain
Keyword(s):  
Operation Time ◽  
Audit And Feedback ◽  
Scrub Nurse ◽  
Patient Identification ◽  
Safe Patient Care ◽  
The Status ◽  
Postoperative Diagnosis ◽  
Operative Findings ◽  
Operative Notes

Introduction: Surgeons must maintain detailed and accurate operative notes as it is important not only for safe patient care but also for research, audit and medicolegal purposes. But literature has shown that many operative notes are incomplete and illegible. Audit and feedback is a useful strategy to improve such practices which our department has been following. Our aim is to study its effectiveness by comparing the quality of operative notes of 2016 with that of 2014. Methods: Total 96 operative notes, 48 each of the year 2014 and 2016 were studied under 22 parameters including 18 suggested by “Good Surgical Practice” guideline. Each operative notes was analyzed by a single observer for completeness. Parameters of the operative notes of two different years were compared and given the status of either improved, deteriorated or unchanged. Results: Only parameters related to patient identification, date, surgeon’s fullname, postoperative plan were complete in both the years. In comparison to earlier year, in 2016 improvement was seen in parameters such as postoperative diagnosis, details of tissue removed, authors details, closure details, operation time and operative difficulties/ complications and deterioration was seen in hospital number, preoperative diagnosis, procedure, fullname of anesthetist, fullname of scrub nurse, operative findings and signature of the surgeon. Conclusion: Improvement in the quality of the operative notes was not adequate with audit and feedback strategy alone. Hence to increase the effectiveness, other methods such as computerized operative notes and aide-memoire should also be introduced.  

scholarly journals Improving the Quality of Operation Notes by Using a Mnemonic and Proforma

2013 ◽  
Vol 95 (6) ◽  
pp. 200-202
Author(s):  
NJG Bauer ◽  
A Wilson ◽  
RJ Grimer
Keyword(s):  
Medical Records ◽  
General Medical Council ◽  
Professional Standards ◽  
Medical Council ◽  
The Public ◽  
Health And Wellbeing ◽  
Standards And Regulations ◽  
The Uk

The General Medical Council is assigned the role of safeguarding and maintaining the health and wellbeing of the public by the Medical Act 1983. All doctors and surgeons in the UK are bound by their professional standards and regulations. Surgeons have to abide by the standards set by The Royal College of Surgeons of England (RCS), which are deemed 'reasonable, assessable and achievable by all competent surgeons'. One of these standards is the overriding duty to ensure that 'all medical records are legible, complete and contemporaneous'. It is vital that all medical and surgical notes document each consultation or procedure that the patient has undergone during his or her stay in hospital.

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