Presentation on theme: "Computer Generated Operation Notes Verity Currall and Tim Chesser Frenchay Hospital, Bristol."— Presentation transcript:
Computer Generated Operation Notes Verity Currall and Tim Chesser Frenchay Hospital, Bristol
Introduction Providing an appropriate operation note is not only good practice 1, it is a professional 2 and legal requirement Operation notes should be 1 : –Legible –Accompany the patient –Sufficiently detailed to enable continuity of care by another doctor
Introduction Increasing importance due to changes in the working practices of junior staff: –ward- (rather than firm-) based teams –European Working Time Directive: shorter shifts more handovers
Introduction Historically, operative notes have been handwritten, causing several problems: –use of abbreviations 3 –poor legibility 4 –lack of description of the procedure 5 These problems are faced in all surgical specialties, but orthopaedic operation notes have come in for particular criticism
Bluespier Bluespier Patient Manager (Bluespier International, Grafton Flyford, Worcestershire, United Kingdom Clinical information system –store outpatient and ward round notes as Word files –track inpatients –manage the trauma board and operating list.
Bluespier Operation notes are generated via proformas –drop down menus –click boxes –free text
Bluespier Operation notes are generated via proformas –drop down menus –click boxes –free text Converted into final operation notes as Word files Checked, saved and printed, with a paper copy placed into the patient’s notes.
Method 4 week prospective audit of all operation notes was conducted both before and after the introduction of Bluespier Before –operation notes were handwritten on paper with only basic prompts After –its use for operation notes was not compulsory, but was strongly encouraged.
Royal College Guidelines 1 Patient name, hospital number, DOB Date and time Elective/emergency procedure Operating surgeon and assistant Consultant Diagnosis Procedure title
Royal College Guidelines 1 Incision Operative findings Procedure details Prostheses Closure/sutures Immediate post-operative instructions Surgeon’s signature
Additional Orthopaedic Criteria 6,7 Tourniquet time and pressure Local anaesthetic Antibiotic/DVT prophylaxis Post op instructions: –Antibiotics –Check x-ray –Weightbearing/mobilisation –ROS –OPA
Results Before computer-generated notes: –119 notes After computer-generated notes: –137 notes –85% computer-generated, 15% written
Discussion Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results Several solutions to the problem have been tried: –aide-memoire in theatre 3 –proforma attached to notes 8 –operation notes produced by word processor using predesigned templates 9
Discussion Quality of the operation notes improved after the introduction of a computer- generated operation note as part of the Bluespier clinical information system Reasonable to attribute the change to the use of the Bluespier system Lack of signature on the printed operation note: –education –electronic signatures
NHS Care Records Service 10 Allow clinicians to access linked records from every NHS organisation used by a patient Both primary and secondary care Details of all investigations and treatment, including operation records
Summary The introduction of computer-generated operation notes has improved their quality in terms of compliance with Royal College guidelines and other orthopaedic criteria Compatible with the wider aims of NHS Care Records Service
References 1.The Royal College of Surgeons of England. Good Surgical Practice. London: The Royal College of Surgeons of England, 2002 2.General Medical Council. Good Medical Practice. London: General Medical Council, 2006 3.Bateman ND, Carney AS and Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg Edinb 1999; 44: 94-5 4.Mathew J, Baylis C, Saklani AP and Al-Dabbagh AR. Quality of operative notes in a district general hospital: a time for change? The Internet Journal of Surgery 2003; 5(1) http://www.ispub.com/ostia/index.php?xmlFilePath=jou rnals/ijs/vol5n1/record.xml http://www.ispub.com/ostia/index.php?xmlFilePath=jou rnals/ijs/vol5n1/record.xml
References 5.Baigrie RJ, Dowling BL, Birch D and Dehn TCB. An audit of the quality of operation notes in two district general hospitals: are we following Royal College guidelines? Ann R Coll Surg Eng (Suppl) 1994; 76: 8- 10 6.British Orthopaedic Association. Knee Replacement - a Guide to Good Practice. London: British Orthopaedic Association, British Association for Surgery of the Knee, 1999 7.British Orthopaedic Association. Primary Total Hip Replacement: A Guide to Good Practice. London: British Orthopaedic Association, 2006 8.Al Hussainy H, Ali F, Jones S, McGregor-Riley JC and Sukumar S. Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma. Injury 2004; 35: 1102-6
References 9.O’Bichere A and Sellu D. The quality of operation notes: can simple word processors help? Ann R Coll Surg Eng (Suppl) 1997; 79(5): 204-8 10.NHS Connecting for Health. Guidance for the NHS about Accessing Patient Information in New and Different Ways and What this Means for Patient Confidentiality. London: NHS Connecting for Health, 2006