1. North Western Deanery Junior Doctors Mr Geoff Chiu StR: Oral and Maxillofacial Surgery 11 th February 2014

2. SurgiNote

3. Operation Note Hand over to post op team Discharge summary Follow up in Spoke Hospital Clinical Governance Clinical Coding Unable to read notes or post op instructions In-efficiency of Clinicians’ time Duplication of information Are notes available? Finding accurate records Code within target? Accurate Coding? Time consuming Discharge Summary to GP < 24 hrs Issues

5. Comments “Much easier to read and locate” “Can understand post operative instructions” “Would be great if all specialties did the same” “Much better easier to read and well set out” “Find it very helpful to have op note typed, always concise and there are no problems like trying to read handwriting” “Improves patient care as you can read all the info“ “Excellent clear and concise” “Typed notes are much easier to identify in the medical notes”

6. SurgiNote: Patient Care Clinical Coding Audit and Research Commissioning Education Improved communication Payment by results Hospital Episode Statistics Quality Assurance Clinical Governance Service Provision and planning LogbookTraining Activity DepartmentalCurrent level of activity SurgeonPatient Related Outcome Measures

7. Shot himself, through chin Squashed in a cheese press! Fell of bike: handle bars caught mouth

9. Neck Dissection Harvesting fibula free flap Ear Chin Micro vascular Anastomosis

10. Pre - operative SCR In- patient SurgiNote Post- operative SCR Somerset Cancer Register

11. Summary The operation note is one of the most important pieces of information that informs us about patient’s surgical care. SurgiNote has been developed and introduced to provide accurate high quality operation notes that can be used by all stakeholders. SurgiNote is innovative and creative. SurgiNote has been quantitatively and qualitatively assessed. SurgiNote has been proven to assist in improving high quality care for patients having surgery.