documentation of surgical procedure

DOCUMENTATION OF SURGICAL PROCEDURE : WHY & HOWHieder A’ala

WHY Documentation and archieving

Reviewing the effectivness of training

Recording the wired cases

Matter of education through case-based approach

HOW ….CRITERIA OF GOOD DOCUMENTATION

Objective data…not subjective Honesty in writing. Continuity Postoperative follow up Good classification of the surgery undertaken Ability to find the procedure without delay Commentary ( on the procedure which was

read prior to procedure ) other than descriptive.

METHODS

1.Program-based

2.Written work

3.Web-based

4.Media

1. PROGRAM BASED

The European Neurosurgical Electronic Logbook of Operations

1. PROGRAM BASED…CONT.

Electronic version of this logbook that helps the trainee to record all operations in an easy and fast way.

Runs under any version of Microsoft Windows

The EANS published a detailed list of operations with minimum and optimum figures for each entry that a trainee must meet at the end of his training

It is not depended on any external programs

CONTINUE

The application is designed to support multiple languages for all text messages and the list of diagnoses

For security reasons all data entered is encrypted

To allow multiple users to access their data on one single computer, the application supports an unlimited number of accounts that can be accessed by one installation of the program

Installation of the application is as straightforward as installing other standard applications

Both lists mentioned can be printed

ROLE OF THE TRAINEE DURING THE OPERATION

This value can either be “T” , “TS”, “C” or “A”: T=Trainee: The trainee has done the

operation. The supervising consultant must not have made a decision/practical manoeuvre significantly affecting the execution of the operation.

TS=Trainee (+Consultant Supervising): The trainee has done the operation but the supervising consultant has made a significant decision/practical manoeuvre during the operation.

C=Component: The trainee has performed component parts during the operation under supervision of a senior surgeon: Positioning, operative approach, closure, drainage, draping, instructions for postoperative care.

A=Assistant: The trainee is the principal assistant during the operation.

2.FORMAL WRITTEN

The eldest way to record

Depends on ability of recorder to fullfil all fields

Obligate us to read prior to write

Nothing not important, keep your mind with the seniors and register every data

2.FORMAL WRITTEN

Not comfortable

All data around us recorded by new technologies

Return to previous cases is not so easy

2.FORMAL WRITTEN

written\My Real Logbook\Trauma Cranial sheet.doc

2.FORMAL WRITTEN ..CONT.

3.WEB-BASED

Few sites were constructed for such mission The data is stored in place other than my

computer

Revision and recording need internet access

The available site is not free

Well organized data and fields, no place for blurred subjects and specific.

CONTINUE The web facilitate revision with trainer

Accredited from well known organisation.

4.MEDIA

Advantages :

Audio recording represents one of the old method to record

Video and photos capturing are new quit methods to save pt. pictures and operative steps

4.MEDIA

Disadvantages :

Continuity not always possible

Needs tool ( high cam zooming )

Needs someone to capture them

Microscopic recording is the best

4.MEDIA

Example : method 1 folder of pics and sound file

4.MEDIA

Example :

4.MEDIA

Example :

4.MEDIA

Example : method 2 microscope recording

THE FINAL WORD

Be honest with your data