Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

Abstract

The RCS has published clear and succinct guidelines dictating the necessity for the documentation of legible and timely surgical operative notes and exactly what should be included.A baseline study within the upper limb unit at our trust showed a 71.1% adherence with the RCS guidelines with an average delay of typing of notes after dictation was 11.6 days. This quality improvement project designed and developed a bespoke electronic surgical notes template built within an existing database driven software within the Trust. After implementation of the templates we found no delays in full operative notes being typed and a 100% adherence with the RCS guidelines. This project significantly improved the quality and timely production of electronic surgical notes within a sustainable electronic software solution.

Evaluating narrative operative reports for endoscopic sinus surgery in a residency training program

“…Their quality audit reinforced these perceptions, as the 40 Roux‐en‐Y gastric bypass NRs they analyzed contained only 62% ± 6.6% of the variables deemed necessary for inclusion. This lack of completeness within NRs was also found in NRs for pancreatic surgery (72.5% completeness for pancreaticoduodenectomy), breast surgery (66% completeness), and upper limb surgery (71.1% completeness) . That fact that our study found a higher average QI inclusion rate (85%) compared to these other studies may reflect the greater emphasis placed on documentation at our institution.…”

“…This lack of completeness within NRs was also found in NRs for pancreatic surgery (72.5% completeness for pancreaticoduodenectomy), breast surgery (66% completeness), and upper limb surgery (71.1% completeness). [13][14][15] That fact that our study found a higher average QI inclusion rate (85%) compared to these other studies may reflect the greater emphasis placed on documentation at our institution. Furthermore, junior residents have an informal template that they follow when learning how to dictate reports which could partially account for the fact that junior residents had a higher QI inclusion percentage than senior residents (87% vs 80%) (P .0169).…”

Improving the documentation of flexible cystoscopy notes: Case for introduction of electronic patient records?

“…A subsequent re-audit, carried out after the implementation of the new electronic FC proforma, established a significant improvement in the quality of FC notes, with 100% compliance with the RCS/BAUS guidelines 1,2 in all fields. By aligning the traditional 'op-note' with a patient discharge letter we were able to not only minimise the duplication of work, but also make these clinical data easily available to all healthcare professionals within our organisation by storing it on a secured network database along with standard discharge letters.…”

“…12,15 Data collected through standardised synoptic operative records can improve patient outcomes, be used as a powerful educational tool, 12 and provide evidence for local and national audits and registries, such as the BAUS' own data project for index procedures. 2 With the growing use of EPR in the United Kingdom, standardised electronic operative records are likely to become the norm in our practice. Our FC proforma was designed specifically to be compatible with the new EPR system currently under development at our institution, with potential for future use across all Trust hospital sites.…”

“…Such system is inefficient and laborious; it has also been linked to poor compliance with the Royal College of Surgeons (RCS) standards on medical record keeping. 2 To the best of our knowledge, this is the first audit focused specifically on evaluating and enhancing the quality of FC documentation.…”