Extracting important information from Chinese Operation Notes with natural language processing methods.

Extracting information from unstructured clinical narratives is valuable for many clinical applications. Although natural Language Processing (NLP) methods have been profoundly studied in electronic medical records (EMR), few studies have explored NLP in extracting information from Chinese clinical narratives. In this study, we report the development and evaluation of extracting tumor-related information from operation notes of hepatic carcinomas which were written in Chinese. Using 86 operation notes manually annotated by physicians as the training set, we explored both rule-based and supervised machine-learning approaches. Evaluating on unseen 29 operation notes, our best approach yielded 69.6% in precision, 58.3% in recall and 63.5% F-score.

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines.

Objectives: Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma. Material and Methods: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020. Results: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p <0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001). Conclusion: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.

Assessment of manual operation note documentation practice: a cross-sectional study.

Background: Operation note documentation captures the key findings and subtle elements of a surgical strategy and is crucial for patient safety. Poor operation note documentation can negatively influence postoperative patient care. This study aimed to assess manual operation note documentation practice. Methods: An institutional-based, cross-sectional study was conducted from 30 March to 30 April 2022, on 240 operation notes of patient data. Data were entered and analyzed by SPSS version 20. According to the RCSE, the Royal College of Surgeons of England, the practice of operation note documentation was rated excellent for each variable when it met 100%, good if it met more than 50%, and poor if it met less than 50% of the operation notes of patient data. Results: All operation notes (n=240) were handwritten. The practice of manual operation note documentation was deemed excellent in two (7.69%), good in 18 (69.2%), and poor in six (23.1%). Residents wrote 84.2% of the operation notes and surgeons and assistants were identified in greater than 94% of the notes, while anesthesia team members were identified in 90.8%. Estimated blood loss was documented in 4.2% of the notes, and the closure technique was described in 64.2%. The operation note templates did not include antibiotic prophylaxis, runner nurse name, or gauze and instrument counts. The urgency of the surgery and time of documentation had a negative relationship, and the seniority of the operation note writer had a positive relationship with manual operative note documentation practice. Conclusions and recommendations: Compared to the standard, all operation note documentation was incomplete and below the standard. We recommend that this comprehensive and specialized hospital administrator implement a new format for operation notes that incorporates RCSE requirements.

A Study in Wad Madani, Sudan: Are We Documenting Operation Notes Effectively?

BACKGROUND: Operative notes represent the critical record of a surgical procedure, encompassing comprehensive details encountered throughout the operation. Recognizing the importance of comprehensive documentation, the Royal College of Surgeons (RCS) developed the Good Surgical Practice guidelines, which emphasize accurately recording every procedure and specifying the necessary parameters for each operative note. These guidelines help maintain high standards of surgical care and patient safety. METHODS: A retrospective review of 88 orthopaedic surgery operative notes for fracture neck of femurs was conducted at Gezira Centre for Orthopedic Surgery and Traumatology (GCOST) from March 12 to May 28, 2022. The review assessed 18 parameters against RCS guidelines. Statistical analysis was performed using Statistical Product and Service Solutions (SPSS, version 25.0; IBM SPSS Statistics for Windows, Armonk, NY), which facilitated comprehensive data examination. RESULTS: In 37 cases (42.05%), the operation notes were written by a medical officer. In 29 cases (32.95%), an orthopaedic resident authored the notes. A specialist documented the notes in 21 cases (23.86%), and a consultant wrote the notes in one case (1.14%). Over 90% of the notes included surgeon and assistant names, procedure names, operative diagnoses, operative procedures, prosthesis details, deep vein thrombosis (DVT) and antibiotic prophylaxis, and signatures. The name of the theatre anaesthetist, elective/emergency details, and additional procedures with reasons were absent in all notes. Less than 50% of the notes documented the time of the procedure, type of incision, operative findings, anticipated blood loss, closure technique specifics, and complications. CONCLUSION: The study emphasizes the shortcomings in the operating notes, underscoring the necessity for training initiatives to enhance the recording by medical officers and orthopaedic trainees. Implementing structured templates that adhere to RCS standards can improve the comprehensiveness and consistency of operating notes, effectively resolving existing discrepancies. Regular audits and feedback sessions are essential for identifying and rectifying persistent issues. It is recommended to arrange workshops and seminars to educate medical officials and trainees on the skills of efficient note-taking and thorough documentation procedures.

Role of Intraoperative Documentation: Avoidable Ulnar Nerve Injury During Implant Removal.

Injuries to the ulnar nerve during open reduction and internal fixation of distal humerus fractures are a well-known phenomenon. However, ulnar nerve injury during implant removal has not been well documented. We performed implant removal in a united distal humerus fracture with the aim of improving the elbow's range of motion. Even with proper surgical precautions in place, the ulnar nerve was damaged during dissection. This report aims to provide insight into this rare phenomenon, and the reasons for this injury are examined retrospectively. The importance of operation notes, the surgical approach, anterior transposition of the nerve, and how this and other factors could have helped the surgeons avoid this complication have also been highlighted.

A Clinical Audit of Operation Notes Documentation and the Impact of Introducing an Improved Proforma: An Audit Cycle.

Introduction Accurate and comprehensive documentation of surgical procedures is vital in healthcare for both medical and legal purposes. This audit assessed adherence to international guidelines for operative note documentation in a general surgery department and the impact of introducing educational initiatives and an enhanced proforma. Methods A retrospective audit of 100 operative notes was conducted in April 2023, followed by a prospective re-audit of another 100 notes in October-November 2023. A checklist based on Royal College of Surgeons (RCS) guidelines assessed 20 parameters. An improved proforma and an awareness session for surgeons were implemented between audits. Data analysis utilized the IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). A paired-sample t-test was used, and a p-value < 0.001 was considered statistically significant. Results The initial audit revealed discrepancies in documentation, with missing information on deep vein thrombosis (DVT) prophylaxis, elective/emergency settings, anticipated blood loss, closure technique specifics, and prosthesis/mesh details. Legibility was satisfactory in 88% of notes. After implementing the proforma and awareness session, significant improvements were observed in all parameters, with documentation rates exceeding 91%. Overall documentation completeness increased from 65.2% to 95.2%. Results of the paired-sample t-test indicated a significant difference before and after the introduction of the new proforma (Mean (M) = 65.2, standard deviation (SD) = 34.3 versus M = 95.2, SD = 4.3) with a p-value of 0.0005. Conclusion Regular audits, surgeon education, and standardized proformas are essential for maintaining high standards in operative note documentation, contributing to improved patient care and safety.

Assessing Adherence to Royal College of Surgeons Guidelines: A Closed-Loop Audit of Operation Notes in a Tertiary Healthcare Unit.

Introduction Accurate, comprehensive, and legible operation notes are essential for maintaining patient records, supporting healthcare professionals, and facilitating research. The study focused on adherence to Royal College of Surgeons (RCS) guidelines established in 2008. Despite the guidelines, poor documentation practices have been reported globally. This audit seeks to address this issue and enhance documentation quality. Methodology The audit evaluated 19 parameters as defined in the 2014 RCS operative note guidelines. Data collection occurred during the initial cycle, spanning from March to April 2023, encompassing all surgical procedures at Hayatabad Medical Complex (HMC). Subsequently, a re-audit took place in July 2023 to gauge enhancements following a survey and educational intervention that took place in June 2023. The process included the formation of an audit team, securing ethical approval, and implementing a comprehensive methodology for data collection and analysis. The study spanned two data collection cycles to comprehensively assess improvements. Results Comparing initial and re-audit cycles (n = 390 and n = 108, respectively), improvements were observed in several documentation aspects. Parameters such as surgery date, elective/emergency classification, and names of key personnel showed significant enhancement. Notable improvements were also seen in the recording of operative details, complications, extra procedures, and post-operative care instructions. In our department, an educational survey was conducted to gain insights into compliance rates. This survey underscored the significance of adhering to RCS guidelines, identified the factors influencing adherence, and proposed strategies for improvement. Conclusion The audit affirmed the significance of adhering to RCS guidelines for operation note documentation. The study demonstrated improvements in documentation practices, emphasising the importance of accurate records for patient care, research, and ethical standards. The findings validate RCS guidelines as a tool for the identification of defects in documentation and thus as a guide that highlights where improvements are necessary. Addressing challenges identified in this audit can drive the department towards becoming a model for RCS guideline adherence and showcasing high-quality surgical documentation and patient-centred care.

Enhancing operative documentation of emergency laparotomy: a systematic review and development of a synoptic reporting template.

INTRODUCTION: Currently, operative reports are narrative and often handwritten, making interpretation difficult and potentially omitting key steps of the procedure. This study undertook a systematic review to determine the current availability of synoptic operative reporting and develop a synoptic operative record template for emergency laparotomy (EL). METHODS: A PROSPERO registered study from January 1st, 2012, to December 31st, 2022, was conducted using PubMed, Scopus, and Web of Science databases in February 2023. KEYWORDS: emergency laparotomy AND operation notes OR operative notes OR documentation OR report OR pro forma OR narrative OR synoptic OR digital OR audio-visual. Studies on paediatric or pregnant patients, systematic reviews, meta-analyses, case reports, editorial comments, and letters were excluded. A synoptic operative record was designed to include key standards in the documentation, as suggested by the Colleges of Surgeons. RESULTS: The literature search yielded 4687 articles, and no relevant published articles were found. A detailed synoptic template was developed, which included 111 fields related to patient demographics, operative findings, interventions, and documentation of key variables associated with patient outcomes. 11 were text boxes, two were related to digital audio-visual uploads, and three facilitated the digital scoring/grading of findings. CONCLUSION: This systematic review identified a limited number of publications reporting synoptic operative reporting, and none related to emergency laparotomy. This novel operative template provides a platform for clear documentation of the surgery performed during emergency laparotomy, potentially facilitating data analysis, resident training, and research, in turn leading to a better understanding of patient outcomes.

It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review.

BACKGROUND: Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. METHODS: A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board. RESULTS: A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. CONCLUSION: This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

Audit on the Quality of Operation Notes in Otolaryngology: Based on Electronic Template.

The operative note is a vital document in the treatment and safety of patients. Detailed recording of operation notes can be quite helpful in research, audit and medico-legal problems. This quality improvement programme was conducted to assess the quality of documentation on an electronic template in comparison to the Royal College of Surgeons (RCS) guidelines. The electronic template used for recording operation notes was compared with RCS guidelines for completeness. A retrospective review of operation notes for all the operations performed by ENT over 1-month period was done. The deficiencies were shared with the department during monthly quality-improvement meetings. A second cycle was carried out in the month of September. The electronic template that is being used in our hospital matches completely with the RCS recommendation. A total of 90 operative records were analysed in the initial audit. The Compliance was 100% in all parameters except five. In the second cycle of audit, compliance was found to be 100% across all parameters, except one-showing considerable improvement. Electronic templates offer easy recording of operation notes without the help of aide memoire, despite which deficiencies do occur. Regular audits are needed to maintain good record-keeping.

Operation notes in orthopaedics: Beliefs and practices in a developing country.

Maintaining accurate and complete operation notes is an essential metric of the quality of surgical care. While developed countries have implemented electronic health records to improve documentation, financial constraints prevent this realisation in the Caribbean. Somewhat paradoxically, previous studies in this area have focussed on 'process' while neglecting the key role of the surgeon. We conducted a 25-item Knowledge, Attitudes and Practices survey of orthopaedic doctors to identify any culturally unique health-related behaviours. Our results indicate that while most doctors understand the importance of operation notes, many are unaware of international note-keeping recommendations. Legibility was identified as a significant issue by 92% of doctors. A disturbing and previously unreported finding from the study revealed that 72% of surgeons would occasionally write the operation notes, although they were not scrubbed in for the procedure. We suggest that future studies examine this peculiar behaviour in greater detail.

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes.

Introduction Operation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines. Methods This was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes. Results Our documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05). Conclusion The use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

Operation Note Transformation: The Application of Lean Six Sigma to Improve the Process of Documenting the Operation Note in a Private Hospital Setting.

Clinical documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost. A surgical operation note (ON) is an essential medicolegal document to ensure continuity of patient care between the surgical operating team and other colleagues, which should be completed immediately following surgery. Incomplete operating surgeon documentation of the ON, in a legible and timely manner, impacts the quality of information available to nurses to deliver post-operative care. In the project site, a private hospital in Dublin, Ireland, the accuracy of completion of the ON across all surgical specialties was 20%. This project sought to improve the accuracy, legibility, and completeness of the ON in the Operating Room. A multidisciplinary team of staff utilised the Lean Six Sigma (LSS) methodology, specifically the Define/Measure/Analyse/Design/Verify (DMADV) framework, to design a new digital process application for documenting the ON. Post-introduction of the new design, 100% of the ONs were completed digitally with a corresponding cost saving of EUR 10,000 annually. The time to complete the ON was reduced by 30% due to the designed digital platform and mandatory fields, ensuring 100% of the document is legible. As a result, this project significantly improved the quality and timely production of the ON within a digital solution. The success of the newly designed ON process demonstrates the effectiveness of the DMADV in establishing a co-designed, value-adding process for post-operative surgical notes.

Where is the nerve? Review of operation note documentation practice for inguinal hernia repair.

INTRODUCTION: Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice may inform postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in their operation notes. METHODS: We carried out a retrospective review of operation notes at a single district general hospital. We analysed operation notes for documentation of identification and intraoperative management (preservation or sacrifice) of the inguinal nerves (iliohypogastric, ilioinguinal, genital branch of genitofemoral nerve). We collected data on the baseline characteristics of the patients, hernia characteristics and primary operating surgeons for subgroup analysis. RESULTS: A total of 100 patients were included in the analysis. Identification of any inguinal nerves (generic 'nerve') was documented in 17% of operation notes. Documentation in the operation notes of named individual nerves was limited. No documentation of intraoperative management of inguinal nerves was found in 83% of operation notes. Preservation of the inguinal nerves (generic 'nerve') was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. CONCLUSION: This study reveals a lack of appreciation of the importance of documenting identification and management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.

Does the development and implementation of a procedure-specific proforma for skin lesion surgery improve quality of operation notes?

BACKGROUND: Operation notes often have omissions and are difficult to locate in patients notes despite clear guidance from the Royal College of Surgeons (RCS) 'Good Surgical Practice' 2014 outlining what should be included in operation notes. Procedure-specific proformas are rarely used by Plastic surgeons despite being utilised by other specialities. With an alarming rise of incidence of skin malignancies there has been an increase in the number of skin lesions referred to Plastic surgeons for excision. The need for reliable, reproducible, accurate and easily accessible operating notes for skin lesion excision is pivotal for continuity of care and treatment planning. This study aimed at comparing the quality of skin lesion operation notes prior-to and after implementation of a procedure-specific proforma in relation to RCS recommendations. METHODS: Fourteen parameters from the recommendations by the RCS 'Good Surgical Practice' 2014 guidelines were used to audit skin lesion operation notes. The study consisted of a retrospective audit of 80 operation notes and a prospective audit of 80 operation notes following the development and implementation of a skin lesion procedure-specific proforma. We assessed and compared the operation notes overall compliance with the RCS guidelines. Statistical analysis highlighting the difference between both groups was performed using the independent sample t-test. RESULTS: After implementation of the skin lesion procedure-specific proforma, the average compliance with the RCS recommendations increased significantly from 87.5% retrospectively to 98.8% prospectively (p-value 0.0414). In 6 of the 14 parameters assessed significant improvements with regards compliance to the guidelines was demonstrated. CONCLUSION: The development and implementation of a skin lesion procedure-specific proforma has demonstrated a significant improvement in the quality of operation notes within a Plastic surgery department which has the potential to minimise omissions and improve continuity of surgical patient care.

Improving the quality of operation notes: Effect of using proforma, audit and education sessions.

BACKGROUND: Both from a medical and legal point of view, the quality of operative notes are important. In this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. METHODS: A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re-audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. The results of each audit were compared. RESULTS: In the first audit, it was found that fourteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), patient position (1.3%), and amount of bleeding (0%). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters. CONCLUSION: This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. The use of proforma provides much better results.

Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals.

BACKGROUND: The General Medical Council states that effective note keeping is essential and records should be clear, accurate and legible. However previous studies of operation notes have shown they can be variable in quality and affect patient safety. This study compares the quality of operation notes against the National Standards set by the Royal College of Surgeons of England and the British Orthopaedic Association (BOA) for improving patient safety. METHODS: Information from Orthopaedic operation notes was collected prospectively over a 2-week period. All elective and trauma operations performed were included and trainees from the region coordinated data collection in 9 hospitals. RESULTS: Data from 1092 operation notes was reviewed. A number of important standards were nearly met including legibility (98.4 %), the name of the operating surgeon (99.3 %) and the operation title (99.1 %). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8 %), documentation of type of anaesthetic used (78.6 %), diagnosis (73.4 %) and findings (80.1 %). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7 % and 48.8 % of cases respectively. CONCLUSIONS: The quality and content of operation notes studied across the region in this period was variable. Use of software programmes in some hospitals for creating operation notes meant that some centres had better results for elements such as date, time and patient identification details. Following this study, greater awareness of the standards combined with additional local measures may improve the quality of operation notes.

Improving the Quality of Oral and Maxillofacial Surgical Notes in an Indian Public Sector Hospital in Accordance with the Royal College of Surgeons Guidelines: A Completed Audit Loop Study.

AIM: Proper and adequate documentation in operation notes is a basic tool of clinical practice with medical and legal implications. An audit was done to ascertain if oral and maxillofacial surgery operative notes in an Indian public sector hospital adhered to the guidelines published by the Royal College of Surgeons England. METHODS: Fifty randomly selected operative notes were evaluated against the guidelines by RCS England with regards to the essential generic components of an operation note. Additional criteria relevant to oral and Maxillofacial Surgery were also evaluated. Changes were introduced in the form of Oral and Maxillofacial Surgery specific consent forms, diagram sheets and a computerized operation note proforma containing all essential and additional criteria along with prefilled template of operative findings. Re-audit of 50 randomly selected operation notes was performed after a 6 month period. RESULTS: In the 1st audit cycle, excellent documentation ranging from 94 to 100 % was seen in 9 essential criteria. Unsatisfactory documentation was observed in criteria like assistant name, date of surgery. Most consent forms contained abbreviations and some did not provide all details. Additional criteria specific to Oral and Maxillofacial Surgery scored poorly. In the 2nd Audit for loop completion, excellent documentation was seen in almost all essential and additional criteria. Mean percentage of data point inclusion improved from 84.6 to 98.4 % (0.001< P value <0.005). The use of abbreviations was seen in only 6 notes. CONCLUSION: Regular audits are now considered a mandatory quality improvement process that seeks to improve patient care and outcomes. To the best of our knowledge, this is the first completed audit on operation notes documentation in Oral and Maxillofacial Surgery from India. The introduction of a computerized operation note proforma showed excellent improvement in operation note documentation. Surgeons can follow the RCS guidelines to ensure standardization of operation notes.

'Smart' electronic operation notes in surgery: an innovative way to improve patient care.

AIMS: Operation notes are the only comprehensive account of what took place during surgery. Accurate and detailed documentation of surgical operation notes is crucial, both for post-operative management of patients and for medico-legal clarity. The aims of this study were to compare operation documentation against the Royal College of Surgeons of England guidelines and to compare the before-and-after effect of introducing an electronic operation note system. METHODS: Fifty consecutive operation notes for inpatients that had undergone emergency orthopaedic trauma surgery were audited. An electronic operation note proforma was then introduced and a re-audit carried out after its implementation. RESULTS: The results after implementation of electronic operation notes, demonstrated a marked improvement. All notes contained an operation note (previously 5/6). Seventy five percent included time of surgery and age of patient (vs. 0% previously). A hundred percent included closure details and antibiotic selection at induction (vs. 60% and 69% respectively). Post-operative instructions improved to 100%. All were typed, making for 100% legibility as compared to only 66% of operation notes with legible hand writing in the initial audit. DISCUSSION/CONCLUSION: We used our pilot audit to target specific information that was commonly omitted and we 'enforced' these areas using drop-down selections in electronic operation note. This study has demonstrated that implementation of an electronic operation note system markedly improved the quality of documentation, both in terms of information detail and readability. We would recommend this template system as a standard for operation note documentation.