computer generated operation notes

Computer Generated Operation Notes

Verity Currall and Tim Chesser

Frenchay Hospital, Bristol

Introduction

• Providing an appropriate operation note is not only good practice1, it is a professional2 and legal requirement

• Operation notes should be1:– 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 abbreviations3 – poor legibility4 – lack of description of the procedure5

• 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

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 Guidelines1

• Patient name, hospital number, DOB

• Date and time

• Elective/emergency procedure

• Operating surgeon and assistant

• Consultant

• Diagnosis

• Procedure title

Royal College Guidelines1

• Incision

• Operative findings

• Procedure details

• Prostheses

• Closure/sutures

• Immediate post-operative instructions

• Surgeon’s signature

Additional Orthopaedic Criteria6,7

• 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

Pre-Bluespier

Pre- v Post-Bluespier

% Pre

Computer

Post Computer

Total Computer Written

DOB 84 96 100 76WB 83 95 96 88Consultant 81 97 100 81Findings 80 96 98 81X-ray 79 76 78 65Position 77 90 92 79OPA 75 87 91 65Tourniquet time 73 89 90 93Tourniquet pressure

52 87 86 100

Local 58 85 85 86Antibiotics 45 87 95 55

Results

% Pre-Computer

Post-Computer

Total Computer Written

Signature 98 12 0 76

Designation 88 11 0 71

Author 20 5 0 33

Time 47 9 0 57

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 theatre3

– proforma attached to notes8

– operation notes produced by word processor using predesigned templates9

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 Service10

• 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

Thank You

References1. 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=journals/ijs/vol5n1/record.xml

References5. 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

References9. 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