Standards of documentation of the surgeon-patient consultation in current surgical practice

Background: This study was designed to assess the reliability of the system whereby junior doctors document the surgeon-patient consultation in general surgical practice in the UK. Methods: A prospective observational study was carried out, with an independent observer recording details of the surgeon-patient consultation and assessing the reliability of documentation. An exact record of the information given by consultants was transcribed in shorthand at the time of consultation. Data were recorded in the categories recommended for notation by the General Medical Council: clinical findings, decisions made, information given to patient and treatment prescribed. Case notes were examined within 24 h of the ward round to ascertain reliability of the documentation. Results: The study population comprised 432 surgeon-patient consultations. There were important deficiencies in the documentation of consultants' clinical findings and management decisions. In addition, information given by consultants to the patients regarding clinical findings and treatment planned (including the need for operation) was recorded in a median of 6 per cent of consultations. Conclusion: This study provides objective evidence of shortfalls in the documentation of the surgeon-patient consultation process. These deficiencies are such that, under present circumstances, the requirements of the General Medical Council with respect to case note documentation are not fulfilled in this setting.