According to GMC Good Medical Practice, clinicians must record their work ‘clearly, accurately and legibly’. Operation notes are no exception and have several key functions. They serve reminder of procedural events, communicate information to the wider team and may be used as evidence when there are complications or complaints. The aim of this audit was to evaluate the legibility of operation notes within the Otolaryngology department at Peterborough City Hospital. Handwritten operation notes were audited from 8 dates chosen at random over a 2-month period (n = 27). Multiple surgeons and a variety of operations were included. Parameters such as legibility of the surgeon’s name, patient identification, date, name of procedure, events, findings, closure and post-op instructions were recorded. Only 11% of the operation notes were legible in all relevant parameters. The surgeon’s name was either absent or not identifiable from the handwriting in 48%. Documentation of the procedure itself and post-op instructions was illegible in 18% and 29% of notes respectively. Illegibility of operation notes is ultimately a patient safety-issue. Not only does it contribute to confusion about what happened during the surgery but also leaves room for error in terms of post-operative care and follow up. The results of the audit were discussed as part of a departmental meeting to highlight the importance of readable operation notes and help foster a culture of good record keeping. A switch to computerised operation notes could ensure legibility and thus improve standards of patient care in the hospital.
A type of disease in which the cells divide abnormally without any control and can invade nearby tissues through epithelial cells is called Carcinoma. Carcinoma is a cancer that starts with in the tissues and that can line from inside and outside the body surface, which arises from cells originating in the endodermal, mesodermal, or ectodermal germ layer during embryogenesis. There are different types of cancer but the most commonly occurring cancer in women is the Brest cancer. This is most common type of cancer in women and this is the second leading cause of cancer death in women after lung cancer. Breast cancer can occur in Women and in some cases, this can be seen rarely in men. This cancers can be identified through the formation of lump in the breast and in some cases there will be the discharge of blood from nipple and the change of the breast and its shape, size and texture of nipple may completely change and invasive in some cases it may be thickening or swelling at that region with slight or severe Irritation, redness or flaky skin in the nipple area. This can be treated by identifying based on the stages of the cancer. This may consist of different therapies such as chemotherapy, radiation, hormone therapy and can be removed through surgery.
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