Computer Generated Operation Notes

1. Computer Generated Operation Notes Verity Currall and Tim Chesser Frenchay Hospital, Bristol

2. 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

3. 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

4. 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

5. 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.

6. Bluespier • Operation notes are generated via proformas • drop down menus • click boxes • free text

9. Bluespier • Operation notes are generated via proformas • drop down menus • click boxes • free text • Converted into final operation notes as Word files

11. 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.

12. Method • 4week 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.

13. Royal College Guidelines1 • Patient name, hospital number, DOB • Date and time • Elective/emergency procedure • Operating surgeon and assistant • Consultant • Diagnosis • Procedure title

14. Royal College Guidelines1 • Incision • Operative findings • Procedure details • Prostheses • Closure/sutures • Immediate post-operative instructions • Surgeon’s signature

15. Additional Orthopaedic Criteria6,7 • Tourniquet time and pressure • Local anaesthetic • Antibiotic/DVT prophylaxis • Post op instructions: • Antibiotics • Check x-ray • Weightbearing/mobilisation • ROS • OPA

16. Results • Before computer-generated notes: • 119 notes • After computer-generated notes: • 137 notes • 85% computer-generated, 15% written

17. Pre-Bluespier

18. Pre- v Post-Bluespier

20. Results

21. 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

22. 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

23. 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

24. 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

25. Thank You

26. References • The Royal College of Surgeons of England. Good Surgical Practice. London: The Royal College of Surgeons of England, 2002 • General Medical Council. Good Medical Practice. London: General Medical Council, 2006 • 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 • 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

27. References • 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 • British Orthopaedic Association. Knee Replacement - a Guide to Good Practice. London: British Orthopaedic Association, British Association for Surgery of the Knee, 1999 • British Orthopaedic Association. Primary Total Hip Replacement: A Guide to Good Practice. London: British Orthopaedic Association, 2006 • 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

28. References • 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 • 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