Most clinical governance meetings focus on "outcomes," but the real foundation of patient safety isn't found in the recovery room—it’s found in the meticulous recording of physiological measurements during the procedure. A perfect surgical result is clinically incomplete if the documentation fails to prove that monitoring recorded meets AAGBI standard.

The Philosophy of Clinical Governance

The "Notes Audit Adams Version" is designed for the medical auditor or consultant who understands that high-stakes medicine requires a forensic level of documentation. It moves the audit process from a subjective "looks okay" to a rigorous, quantified instrument of quality control. By standardizing the verification of Pre-op assessment and History and examination, the system creates an objective map of clinical diligence. It acknowledges that in anaesthesia, the "empty box" on a chart is a risk factor that must be identified and corrected before it leads to a systematic failure.

The Architecture of Safety Verification

The structure of this library is built to audit the entire perioperative journey, ensuring that no technical detail is overlooked.

  • Pre-Operative Triage: Fields for Initial observations, Investigations recorded, and ASA recorded verify that the baseline patient state was correctly established before the first dose of induction agent.
  • Intra-Operative Precision: The audit probes the depth of the anaesthetic record, checking for the documentation of Induction type, Airway type, and Ventilation type. Binary fields for Drugs recorded and Fluids recorded distinguish between "minimal" notes and "adequate" clinical records.
  • The Chain of Accountability: The system tracks the presence of signatures for Vascular access and the specific recording of the Case anaesthetist and Responsible consultant. This ensures that the lines of responsibility are as clear in the record as they are in the theater.

Compliance with Global Standards

The core value of this tool is its focus on regulatory alignment. By specifically auditing whether the Monitoring used meets the AAGBI (Association of Anaesthetists of Great Britain and Ireland) standard, the library turns individual chart reviews into a broader assessment of institutional compliance. The capture of NCEPOD category and Surgical infiltration record provides the granular data required for national-level reporting and specialized clinical research.

Power Feature: Gap Analysis through Choice Fields

By utilizes Memento’s ability to group by choice field status—distinguishing between "Yes," "No," and "Incomplete"—you can instantly generate a gap analysis for your department. You don't need to manually tally scores; you simply filter for all entries where Patient explanation/discussion is "Not filled in" to identify specific areas for training and protocol refinement. It transforms a collection of individual audits into a powerful strategic engine for clinical excellence, ensuring that the highest standards of safety are not just practiced, but proven.