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The paper aims to assess the quality (content and legibility) of handwritten operation notes and the reader's interpretation of legibility by clinical seniority.

Consecutive elective and emergency general surgical operations over a six-week period from September 2011 at one hospital were retrospectively collected. Non-retrieval of operation notes, typed notes and endoscopies were excluded. The content of each operation note was assessed against a 26-item checklist. Legibility was assessed by 4 readers (2 Foundation Doctors and 2 Registrars in General Surgery) using an original objective scoring system.

A total of 404 operations were identified; 45 were excluded following review of operation notes. Operation notes were derived from 12 consultants and 11 registrars. Analysis of the content score suggested that time of procedure (1 per cent), ASA grade (1 per cent) and blood loss (5 per cent) were poorly reported. Clinical indication and post-operative instructions were documented in only 52 per cent and 66 per cent of operation notes respectively. Registrar notes had a higher content score compared with consultant notes (15.8 vs 13.5, p<0.001). Legibility scores were reported to be higher for Registrar readers, compared with Foundation Doctor readers (OR 1.95, 95 per cent CI 1.75-2.18, p<0.001). Registrar-written notes had higher legibility scores compared with consultants (OR 19.0, 95 per cent CI 11.6-31.2, p<0.001).

The quality of handwritten notes varies. Registrar-written notes are more content-rich and legible.

Clinical seniority and specialty training may improve the interpretation of handwritten operation notes. This study adds to growing evidence supporting the widespread adoption of a computerized immediate operation note.

An objective scoring system to assess legibility of operation notes written as freehand was used. Also, legibility according to the reader's seniority in clinical training was evaluated.