Surgical doctors’ adherence to the RCS and GMC medical documentation guidelines: 0061

摘要: Aim: The audit examined how closely surgical doctors at the Princess Royal University Hospital (PRUH) adhered to medical documentation guidelines stipulated in GMC: Good Medical Practice and Royal College of Surgeons (RCS): Good Surgical practice.Method: Two Surgical doctors evaluated surgeons’ documentation in medical notes, against GMC/RCS documentation guidelines. 52 notes were reviewed; 18 from accident and emergency (A&E) and 34 from inpatient entries. After collating the results, a strategy was implemented to improve future outcomes. A poster stipulating GMC/RCS documentation guidelines was advertised across the surgical department for one month, and notes subsequently re-audited.Result: Pre-strategy results showed overall good adherence to GMC/RCS guidelines, with handwriting legibility in inpatient notes scoring 93% compared with A&E notes scoring 75% legibility. Post …