Background Proper documentation is essential for patient care. The popularity of artificial intelligence (AI) offers the potential for improvements in neurosurgical note-writing. This …
Clinical documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost. A surgical …
SH Abbas, S Singh, R Sundran, K Akbari… - … Journal of Surgery …, 2016 - journals.lww.com
Methods: Nineteen parameters based on the RCSEng 'Good Surgical Practice'2014 guidelines were used to audit laparoscopic appendicectomy operation notes. The study …
MD Muneeb, MAN Baig, M Kamran… - Pakistan Journal of …, 2024 - pmc.ncbi.nlm.nih.gov
Objective: To evaluate the quality and standard of hand-written operative notes in a teaching institute. Methods: This prospective study was carried out in the department of surgery …
A Vergis, GGRJ Johnson, K Hardy, J Gu, A Sharples… - Surgical …, 2022 - Springer
Background Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for …
SM Strong, AA McDougall… - Facts, Views & …, 2024 - pmc.ncbi.nlm.nih.gov
Background No large-scale databases exist of pregnancy outcomes and rate of uterine rupture for women after myomectomy, resulting in inconsistent antenatal counselling and …
EO Oladeji, S Singh, K Kastos - Cureus, 2022 - ncbi.nlm.nih.gov
Background An operative note (op note) is a vital medical record of remarkable clinical, medico-legal and academic relevance. The Royal College of Surgeons (RCS) has set out a …
Introduction Operation notes are fundamental for clinical, academic and medico-legal purposes. Good Surgical Practice (2014) provides guidelines to assist note completion but …
DS Bhatti, R Ahmad, A Asad - Cureus, 2020 - ncbi.nlm.nih.gov
Methods and results An audit was conducted from April to September 2019 at District Headquarter Hospital in Rawalpindi, Pakistan. We analyzed 215 operative notes of elective …