Scottish Audit of Surgical
Mortality
Stirling, 8th September 2005
[email protected]
SASM
• Completion of
proformas (surgeon/
anaesthetist)
• First line assessment +
• Case Note Review
• Feedback
One way to do Case Note
Review:
Case Notes Arrive
Set notes aside
Keep notes safe
Keep notes together
Treat like a formal patient or legal opinion
Identify time within the “next week” to do
the case note review.
How to do Case Note Review:
 Quiet setting
 Allow adequate time
(?1 hour)
 Adequate space
 No interruptions
 Skim through the
notes to determine
their layout
 (re-)organise the bits
 Pay particular
attention to:
 Clinical notes (OP,
ward, HDU/ITU)
 Operation note(s)
 Discharge summaries
 Nursing notes
 Integrated care
pathways.
Actually Doing the Case Note
Review:



i.
ii.
iii.
iv.
v.
Read through the (re- ) organised case notes
Make notes as you go
Write/type/dictate a
background,
a sequence of events,
learning points,
areas of good practice and
deficiencies of care (if any)
Actually Doing the Case Note
Review - Revision:
 Have I been thorough?
 Have I been concise (<1page A4)?
 Can I cite any evidence in support of my opinion?
 How have I phrased it/ would I be upset if I
received this review?
 What are the deficiencies of care: the adverse
events, areas of concern or for consideration?
 Would I be willing to sign this?
Future Considerations:
Quality reviews
Transparency
How do we recompense assessors?
Root Cause Analysis