Presentation on theme: "Computer Generated Operation Notes"— Presentation transcript:
1Computer Generated Operation Notes Verity Currall and Tim ChesserFrenchay Hospital, Bristol
2IntroductionProviding an appropriate operation note is not only good practice1, it is a professional2 and legal requirementOperation notes should be1:LegibleAccompany the patientSufficiently detailed to enable continuity of care by another doctorProviding an appropriate operation note is not only good practice1, it is a professional2 and legal requirement.The operation note should be legible, accompany the patient and have sufficient detail to enable continuity of care by other healthcare staff1.
3IntroductionIncreasing importance due to changes in the working practices of junior staff:ward- (rather than firm-) based teamsEuropean Working Time Directive:shorter shiftsmore handoversThe last is particularly important, due changes in the working practices of junior staff, including ward- (rather than firm-) based teams and shorter shifts, with more handovers, because of the European Working Time Directive.
4IntroductionHistorically, operative notes have been handwritten, causing several problems:use of abbreviations3poor legibility4lack of description of the procedure5These problems are faced in all surgical specialties, but orthopaedic operation notes have come in for particular criticismHistorically, operative notes have been handwritten. This has given rise to several problems, including the use of abbreviations3, poor legibility4 and lack of description of the procedure5.These problems are faced in all surgical specialties, but orthopaedic operation notes have come in for particular criticism, having been described as “untidy one-liners”6. Although this is probably a little harsh, this study investigates whether the use a computerised system can improve the quality of orthopaedic trauma operation notes.
5BluespierBluespier Patient Manager (Bluespier International, Grafton Flyford, Worcestershire, United KingdomClinical information systemstore outpatient and ward round notes as Word filestrack inpatientsmanage the trauma board and operating list.The Bluespier Patient Manager was introduced into an orthopaedic trauma unit.This clinical information system is used to store outpatient and ward round notes as Word files, track inpatients and manage the trauma board and operating list. A new patient episode is created when someone is seen for the first time with a new diagnosis by selecting the patient from a list created by an interface of Bluespier with the current Trust Patient Administration System (PAS) (online HL7).An extra computer workstation with intranet access, plus a printer, were required in the trauma theatre to allow the generation and printing of operation notes by the surgeon. The operative notes, along with the other documents mentioned above, can, however, be accessed by approved healthcare workers (generally medical and nursing staff), via a password-protected system accessible from every computer in the hospital. In addition, Bluespier has research/audit functions, which allow the system to be interrogated to find, for example, the records of all patients undergoing a specified procedure in a particular timescale.
6Bluespier Operation notes are generated via proformas drop down menus click boxesfree textOperation notes are also generated via proformas, which use a combination of drop down menus (Figure 1), click boxes (Figure 2) and free text.
9Bluespier Operation notes are generated via proformas drop down menusclick boxesfree textConverted into final operation notes as Word filesThese are converted into final operation notes as Word files (Figure 3).These are then checked, saved and printed by the author, with a paper copy placed into the patient’s notes. It is also possible to type an operation note as free text in a Word document.
11Bluespier Operation notes are generated via proformas drop down menusclick boxesfree textConverted into final operation notes as Word filesChecked, saved and printed, with a paper copy placed into the patient’s notes.These are then checked, saved and printed by the author, with a paper copy placed into the patient’s notes. It is also possible to type an operation note as free text in a Word document.
12Method4 week prospective audit of all operation notes was conducted both before and after the introduction of BluespierBeforeoperation notes were handwritten on paper with only basic promptsAfterits use for operation notes was not compulsory, but was strongly encouraged.A four week prospective audit of all operation notes was conducted both before and after the introduction of Bluespier.Prior to its introduction, operation notes were handwritten on paper with only basic prompts (patient details, procedure and indication).Bluespier’s use for operation notes was not compulsory, but was strongly encouraged.
13Royal College Guidelines1 Patient name, hospital number, DOBDate and timeElective/emergency procedureOperating surgeon and assistantConsultantDiagnosisProcedure titleThe audit standards were based on criteria set out by the Royal College of Surgeons of England1 ...
14Royal College Guidelines1 IncisionOperative findingsProcedure detailsProsthesesClosure/suturesImmediate post-operative instructionsSurgeon’s signature
15Additional Orthopaedic Criteria6,7 Tourniquet time and pressureLocal anaestheticAntibiotic/DVT prophylaxisPost op instructions:AntibioticsCheck x-rayWeightbearing/mobilisationROSOPAas well as additional orthopaedic criteria, based partly on British Orthopaedic Association guidelines7,8 …Data were collected from the paper operative notes - whether written or computer-generated - in the patients’ medical records. Tick box proformas for the presence or absence of the criteria described above were filled in by the first author, bearing in mind that not all criteria would be applicable to every procedure (e.g. prostheses). The use of a tourniquet and/or local anaesthetic was cross-checked with the nursing record.
16Results Before computer-generated notes: After computer-generated notes:137 notes85% computer-generated, 15% writtenOne hundred and nineteen operation notes were reviewed before the introduction of computer-generated notes and 137 notes afterwards. Of these, 116 (85%) were generated via computer and 21 (15%) were handwritten.
17Pre-BluespierIn the notes from before the introduction of Bluespier, the criteria were generally met, but the documentation of tourniquet (pressure 17/33 = 52%; time 24/33 = 73%) and local anaesthetic (14/24 = 58%) use intraoperatively were poor. This was also the case for postoperative instructions, including check x-ray (67/85 = 79%), outpatient appointment (73/97 = 75%), suture removal (60/81 = 74%) and postoperative antibiotics (35/78 = 45%).
18Pre- v Post-BluespierFrom a graphical comparison between the two sets of results (Figure 4), it can be seen that there were large differences in some of the criteria.For these criteria, the post-Bluespier notes results were also divided into those operation notes generated using the computer and those which were still handwritten.
19% Pre Computer Post Computer Total Written 84 96 100 76 83 95 88 81 97 DOB849610076WB839588Consultant8197Findings8098X-ray797865Position779092OPA758791Tourniquet time738993Tourniquet pressure5286Local5885Antibiotics4555Of the criteria where the post-computer notes scored more highly than the pre-computer notes, most (including general details, operative details and post-operative instructions) did so because the computer-generated notes were of a higher quality (ie had higher scores on the criteria). The post-Bluespier written notes had similar scores to the pre-Bluespier notes.There were, however, a few exceptions (shown in red). The documentation of local anaesthetic and tourniquet use was much better in the post-Bluespier notes, but this improvement took place in both the computer-generated and written notes. There is no obvious explanation for this, although both criteria scored particularly badly before the introduction of computer-generated notes.
20Results % Pre-Computer Post-Computer Total Computer Written 98 12 76 Signature981276Designation881171Author20533Time47957The only areas in which the computer-generated notes were worse than the handwritten notes were in the details of the author (name, designation and signature) and time of day, none of which are routinely contained in the computer-generated notes. With the exception of the signature, however, the other details are available from a separate audit trail function of the system.
21DiscussionPrevious audits of the quality of general surgical operation notes in district general hospitals have shown variable resultsSeveral solutions to the problem have been tried:aide-memoire in theatre3proforma attached to notes8operation notes produced by word processor using predesigned templates9Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results4,5. Several solutions to the problem have previously been tried. The use of an aide-memoire in theatre has improved the quality of notes in ENT departments, in terms of patient details and abbreviations3, as well as adherence to Royal College guidelines9. The introduction of a proforma in trauma and orthopaedic surgery significantly improved the documentation of several criteria, including patient number, consultant, diagnosis, position and the use of tourniquets and antibiotics10.With the advent of the National Programme for IT (NPfIT), computer generated notes are the next logical step. A computerised template with drop-down menus and free text proved better than handwritten notes in ENT emergency clinics11. An early database management system for general surgery was effective in collecting data and allowed the generation of operation notes, but their quality was not investigated12. In another study, operation notes produced by word processor using predesigned templates scored more highly than written notes using a proforma13.
22DiscussionQuality of the operation notes improved after the introduction of a computer-generated operation note as part of the Bluespier clinical information systemReasonable to attribute the change to the use of the Bluespier systemLack of signature on the printed operation note:educationelectronic signaturesOur results show that the quality of the operation notes in most criteria improved after the introduction of a computer-generated operation note as part of the Bluespier clinical information system. Apart from the documentation of local anaesthetic and tourniquet use, the quality of written notes had not improved over the same period, so it is reasonable to attribute the change to the use of computer-generated operation notes. The main deficiency was the lack of signature on the final printed operation note, but should be easy to remedy with education or the use of electronic signatures.Although ease and speed of use were not specifically investigated in this study, the general impression of the users was that the system is easy to use, although some of the proformas need minor alterations. It initially takes a few minutes more to produce a computer-generated note than a written one, but this decreases with familiarity and the use of personal default settings. There are also considerable time savings when needing to check an operation note if the paper notes are not readily available (for example, when a patient is readmitted or the notes have been lost before an outpatient appointment). In addition, audit and log book generation is easily achievable.
23NHS Care Records Service10 Allow clinicians to access linked records from every NHS organisation used by a patientBoth primary and secondary careDetails of all investigations and treatment, including operation recordsThe NHS Care Records Service (CRS) will take several years to introduce, but will eventually allow clinicians to access linked records from every NHS organisation used by a patient (from both primary and secondary care), with details of all investigations and treatment, including operation records14. The Bluespier system achieves this in terms of operation notes, as well as ward round and outpatient notes.Development will soon allow interface with PACS and laboratory investigations to allow a fully integrated system. Currently, 16 hospitals in the United Kingdom and Ireland (including ours) are using the Bluespier system15.
24SummaryThe introduction of computer-generated operation notes has improved their quality in terms of compliance with Royal College guidelines and other orthopaedic criteriaCompatible with the wider aims of NHS Care Records ServiceIn conclusion, the introduction of computer-generated operation notes has improved their quality in terms of compliance with both Royal College criteria and other orthopaedic criteria.It is also compatible with the wider aims of the NHS Care Records Service
26ReferencesThe Royal College of Surgeons of England. Good Surgical Practice. London: The Royal College of Surgeons of England, 2002General Medical Council. Good Medical Practice. London: General Medical Council, 2006Bateman 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: 94-5Mathew 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)
27ReferencesBaigrie 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: 8-10British Orthopaedic Association. Knee Replacement - a Guide to Good Practice. London: British Orthopaedic Association, British Association for Surgery of the Knee, 1999British Orthopaedic Association. Primary Total Hip Replacement: A Guide to Good Practice. London: British Orthopaedic Association, 2006Al 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:
28ReferencesO’Bichere A and Sellu D. The quality of operation notes: can simple word processors help? Ann R Coll Surg Eng (Suppl) 1997; 79(5): 204-8NHS 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