文章基本信息

标题：An audit of orthopedic operation notes: what are we missing?
本地全文：下载
作者：A K Ghosh
期刊名称：Clinical Audit
电子版ISSN：1179-2760
出版年度：2010
卷号：2
页码：37-40
DOI：10.2147/CA.S9665
出版社：Dove Medical Press Ltd
摘要：The importance of complete and legible operation notes is indisputable. Orthopedic operation notes at the author’s institution were audited against guidelines regarding content and legibility. Although of generally good standard it was found that in some cases important information was being missed and that a high proportion of notes had sections that were deemed illegible. A computerized proforma for writing notes has been proposed.
关键词：orthopedic; operation notes; audit