RECORD KEEPING

• Essential that patients receive written note describing diagnosis, procedure performed
• All records should be clear, accurate, complete, signed

Admission note/preoperative note

• Preoperative assessment, management plan, patient consent should be clearly documented

Delivery book

• Chronological list of deliveries, procedures, interventions, complications, outcomes for mother and baby

Operating theatre records

• Patient identity
• Procedure performed: both major and minor
• Personnel involved
• Complications
• Blood loss
• Standardized forms save time, encourage staff to record required information

Postoperative notes

• All patients assessed at least once after surgery
• Vital signs, patient’s condition accurately recorded

Progress note

• Need not be long, must comment on patient’s condition, note any changes in management plan
• Should be signed by person writing note

Discharge note

• Admitting and definitive diagnoses
• Summary of patient’s course in hospital
• Outpatient instructions:
  • medication details
  • planned follow-up
  • suture removal, special wound care