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Short Report:Template operative note, a better documentation.

Author(s)
Fareed Ahmed Shaikh Aga Khan University Hospital Karachi, Pakistan,
Abdul Rehman Alvi Aga Khan University Hospital Karachi, Pakistan,
Noman Shahzad Aga Khan University Hospital Karachi, Pakistan,
Tanzeela Gala Royal free Hospital,London, UK,
Ghulam Murtaza South City Hospital, Karachi, Pakistan
Abstract
Operative notes are a valuable part of patient's medical record, and carry the medico-legal significance. One way of improving it is to introduce the template form operative notes. Only few studies have been done worldwide to compare both the forms of operative notes. This cross-sectional study was conducted in the department of General Surgery, AKUH. This included the patients who underwent Laparoscopic cholecystectomy (Complying with inclusion criteria) from August 2013 till March 2014. Out of 24 patients, 19 were females. The completeness of data in template group was significantly better than traditional group (79.2% vs. 8.3%). There was no significant difference among the residents of different level (writing the notes) and the completeness of data in both the groups. Similarly the timing of day did not affect significantly on the completeness.
Publication Details
Page(s) 409-411
DOI DOI not available
Published Journal: Journal of Pakistan Medical Association, Volume: 69, Issue: 3, Year: 2019

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Keywords
Completeness of data, Template operative notes
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