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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
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