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Year : 2021  |  Volume : 27  |  Issue : 2  |  Page : 199-201

Documentation in surgical practice

Department of Surgery, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India

Correspondence Address:
Dr. Sanjay Kumar Jain
Department of Surgery, Gandhi Medical College and Hamidia Hospital, Royal Market, Bhopal - 462 001, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ksj.ksj_34_21

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Documentation and record keeping are the important aspects of health-care practice, and peri-operative practice is no exception to this rule. Recording every activity or intervention that a patient receives is a legal. The clarity of information is essential. Hence, the surgeon has to record appropriate information in the appropriate and meaningful language in a timely manner maintaining confidentiality. Thus, record keeping is a 'part of the professional duty'. In this article, the essential parts of surgical case recording are highlighted.

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