ImprovIng Trauma OperatIon Notes at an EmergIng Trauma UnIt in the RegIonal Trauma Network

Malik, Shahbaz S.; Nogaro, M-C.; Shenoy, Ramya; Mitchell, Piers D.

doi:10.1308/003588413x13643054410386

Cited by 4 publications

(4 citation statements)

References 4 publications

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“…In this study, the majority (67%) of the operative notes were written by trainees in the initial audit. For a training institution, this is commendable and the results are similar to previous studies7. However, there is no formal training for trainees in our setting on operative note writing according to standard guidelines.…”

Section: Discussionsupporting

confidence: 83%

“…There were significant deficiencies in the completion of details for all the other components on assessment such as age, sex, date of operation, time of operation, name of assistant, name of scrub nurse and name of theatre anesthetist. The completion rate was low in comparison to other studies4–7,13,14. Clinical audits and comparative studies are governed by availability of good quality study designs and adequate detailed information.…”

Section: Discussionmentioning

confidence: 84%

“…Operative notes are often produced in a court of law as documentary evidence, either by the plaintiff or the defendant1,2. Errors in the recording or interpretation of operative notes can compromise patient safety and care, lengthen hospital stays unnecessarily and leave authorities open to litigation7,8.…”

Section: Introductionmentioning

confidence: 99%

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The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

Nyamulani

Mulwafu

2018

Mal. Med. J

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BackgroundOperative note writing is one of the fundamental parts in surgical practice. Accurate documentation is critical, to be of value when used for postoperative care, research, academic purposes and medical legal clarity. Although guidelines guiding surgeons on how to write operative notes exist, deficiencies are noted worldwide.PurposeTo assess quality of hand-written operative notes in surgical unit at Queen Elizabeth Central Hospital (QECH) using the RCSEng guidelines as a standard.MethodsTo identify key areas of weaknesses, a sole observer in this study assessed prospectively the quality of operative notes in our setting. The audit loop was completed after adoption of new interventions.ResultsSixty-seven percent of the notes were written by trainees in both audits. Key areas of missing data were on time of performing the operation, urgency, estimated blood loss, complications and extra procedure in the first audit, with a frequency of 0%, 2%, 14%, 38% and 11% respectively. The results improved significantly to 62%, 84%, 62%, 70%and 32% respectively [p<0.05] in the second audit. Half of the postoperative care instructions were inadequate with 29% of the notes partially illegible or completely illegible.ConclusionThe study identifies significant deficiencies in our operative note writing. Surgeon's education, use of detailed pro formas with heading prompts and aide memoirs for vital information play a major role in better note completion. The role of electronic health records is highlighted.

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Section: Discussionsupporting

confidence: 83%

Section: Discussionmentioning

confidence: 84%

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The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

Nyamulani

Mulwafu

2018

Mal. Med. J

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“…The current epidemic of defensive practice due to fear of medicolegal repercussions has had an extensive impact on neurosurgical documentation practices, resulting in more detailed documentation of procedures (7). Despite guidelines being available for the documentation of operative notes (8), many studies have demonstrated the inadequate quality of operative notes with much salient information missing, including the nature of the surgery, indication of surgery, estimated blood loss, incidence of complications, and postoperative instructions (6,(9)(10)(11). Such non-standardised documentation can lead to greater manual review times, making the extraction of relevant information more labour-intensive.…”

Section: Introductionmentioning

confidence: 99%

Natural language processing for the automated detection of intra-operative elements in lumbar spine surgery

Biswas,

McMenemy,

Sarkar

et al. 2023

Front. Surg.

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BackgroundThe aim of this study was to develop natural language processing (NLP) algorithms to conduct automated identification of incidental durotomy, wound drains, and the use of sutures or skin clips for wound closure, in free text operative notes of patients following lumbar surgery.MethodsA single-centre retrospective case series analysis was conducted between January 2015 and June 2022, analysing operative notes of patients aged >18 years who underwent a primary lumbar discectomy and/or decompression at any lumbar level. Extreme gradient-boosting NLP algorithms were developed and assessed on five performance metrics: accuracy, area under receiver-operating curve (AUC), positive predictive value (PPV), specificity, and Brier score.ResultsA total of 942 patients were used in the training set and 235 patients, in the testing set. The average age of the cohort was 53.900 ± 16.153 years, with a female predominance of 616 patients (52.3%). The models achieved an aggregate accuracy of >91%, a specificity of >91%, a PPV of >84%, an AUC of >0.933, and a Brier score loss of ≤0.082. The decision curve analysis also revealed that these NLP algorithms possessed great clinical net benefit at all possible threshold probabilities. Global and local model interpretation analyses further highlighted relevant clinically useful features (words) important in classifying the presence of each entity appropriately.ConclusionsThese NLP algorithms can help monitor surgical performance and complications in an automated fashion by identifying and classifying the presence of various intra-operative elements in lumbar spine surgery.

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A Review of Operation Theater Notes in a Tertiary Care Center

Lakshmikantha¹,

Lakshman²

2020

Indian J Surg

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ImprovIng Trauma OperatIon Notes at an EmergIng Trauma UnIt in the RegIonal Trauma Network

Cited by 4 publications

References 4 publications

The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

Natural language processing for the automated detection of intra-operative elements in lumbar spine surgery

A Review of Operation Theater Notes in a Tertiary Care Center

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