1 General principles of management of patients

Communication is the imparting of knowledge and understanding. Good communication is crucial for the surgeon in his or her daily interaction with patients. The nature of any interaction between surgeon and patient will depend very much on the context of the ‘interview’, whether you know the patient already, and on the quantity and type of information that needs to be imparted. As a general rule, the basis of good communication requires the following:

The Royal College of Surgeons’ guidelines state that each clinical history sheet should include the patient’s name, date of birth, and record number. Each entry should be timed, dated, and signed, and your name and position (e.g. SHO for ‘senior house officer’ or SPR for ‘specialist registrar’) should be clearly written in capital letters below each entry. You should also document which other medical staff were present with you on ward rounds or when seeing a patient (e.g. ‘ward round—SPR (Mr X)/SHO/HO’).

Contemporaneous note keeping is an important part of good clinical practice. Medical notes document the patient’s problems, the investigations they have undergone, the diagnosis, and the treatment and its outcome. The notes also provide a channel of communication between doctors and nurses on the ward and between different medical teams. In order for this communication to be effective and safe, medical notes must be clearly written. They will also be scrutinized in cases of complaint and litigation. Failure to keep accurate, meaningful notes which are timed, dated, and signed, with your name written in capital letters below, exposes you to the potential for criticism in such cases. The standard of note keeping is seen as an indirect measure of the standard of care you have given your patients. Sloppy notes can be construed as evidence of sloppy care, quite apart from the fact that such notes do not allow you to provide evidence of your actions! Unfortunately, the defence of not having sufficient time to write the notes is not an adequate one, and the courts will regard absence of documentation of your actions as indicating that you did not do what you said you did.

Do not write anything that might later be construed as a personal comment about a patient or colleague (e.g. do not comment on an individual’s character or manner). Do not make jokes in the patient’s notes. Such comments are unlikely to be helpful and may cause you embarrassment in the future when you are asked to interpret them.

Try to make the notes relevant to the situation so, e.g. in a patient with suspected bleeding, a record of blood pressure and pulse rate is important, but a record of a detailed neurological history and examination is less relevant (unless, e.g. a neurological basis for the patient’s problem is suspected).

The results of investigations should be clearly documented in the notes, preferably in red ink, with a note of the time and date when the investigation was performed.

Avoid the use of abbreviations. In particular, always write LEFT or RIGHT in capital letters, rather than Lt/Rt or L/R. A handwritten L can sometimes be mistaken for an R and vice versa.

We include the following information on operation notes:

If a consultant is supervising you, but is not scrubbed, you must clearly state that the ‘consultant (named) was in attendance’.

The aviation, nuclear, and petrochemical industries are termed ‘high reliability organizations’ (HROs) because they have adopted a variety of core safety principles that have enabled them to achieve safety success, despite ‘operating’ in high-risk environments. Surgeons can learn much from HROs and can adopt some of these safety principles in surgical practice in order to improve safety in the non-technical aspects of care.

Foremost amongst the safety principles of HROs are: