Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

Nzenza, Tatenda; Manning, Todd; Ngweso, Simeon; Perera, Marlon; Sengupta, Shamik; Bolton, Damien; Lawrentschuk, Nathan

doi:10.1111/ans.14239

Cited by 11 publications

(10 citation statements)

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“…Nevertheless, narrative and synoptic reports had missing information, which the author's training level may partly explain. The surgeons described a bell-curve response when determining who can write a complete operation report, a finding reiterated in other studies [11][12][13] and that has previously been described as the 'intermediate effect'. Junior learners recall very few facts in a clinical situation as they do not have the knowledge and experience to do so.…”

Section: Discussionmentioning

confidence: 64%

Surgeons' perspectives on operation report documentation

Fink

Holmes

Monagle

et al. 2023

ANZ Journal of Surgery

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BackgroundOperation report documentation is essential for safe patient care and team communication, yet it is often imperfect. This qualitative study aims to understand surgeons' perspectives on operation report documentation, with surgeons reviewing cleft palate repair operation reports. It aims to determine how surgeons write an operation report (in narrative and synoptic report formats) and explore the consequences of incomplete documentation on patient care.MethodsA qualitative semi‐structured interview was conducted with cleft surgeons who were asked to consider operation reports and hypothetical clinical cases. Eight operation reports performed at one centre for cleft palate repair were randomly selected for review.ResultsAn operation report's purpose—patient care, complication documentation, future surgery, and research—will influence the detail documented. All cleft palate repair operation reports had important information missing. Synoptic report writing provides clearer documentation; however, narrative report writing may be a more robust communication and education tool. Surgeons described a bell‐curve response in the level of training required to document an operation report—residents knew too little, fellows documented clearly, and Consultants documented briefer reports to highlight salient points.ConclusionsAn understanding of surgeons' perspectives on operation report documentation is richer after this study. Surgeons know that clear documentation is essential for patient care and a skill that must be taught to trainees; barriers may be the documentation method. The flexibility of a hybrid operation report format is necessary for surgical care.

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Section: Discussionmentioning

confidence: 64%

Surgeons' perspectives on operation report documentation

Fink

Holmes

Monagle

et al. 2023

ANZ Journal of Surgery

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“…Whilst the impact of suboptimal communication on these cases is not clear, replacing handwritten operation notes with electronic versions may aid in reducing these numbers. In WA public hospitals, registrars commonly write the operation notes and whilst registrar quality has previously been reviewed [ 8 ], this study provides additional insight into rural applicability and consultant performance.…”

Section: Discussionmentioning

confidence: 99%

Typed Operation Notes in Rural Western Australia: Improving Patient Care

Davis¹,

Mckittrick²,

Wagner³

2022

Cureus

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Introduction: Given the geographical area of the Kimberley region in Western Australia (WA) and the nomadic nature of its residents and medical staff, widespread access and clarity of surgical clinical information are necessary to provide accurate and timely post-surgical care. The aims of this project were: to evaluate the quality of operation notes and secondly, to evaluate multidisciplinary staff perceptions of the impact of the introduction of typed operation notes for general surgery in the Kimberley region from 2019 to 2020. Methods: The quality of 100 general surgery operation notes (50 typed and 50 handwritten) were reviewed against the Royal College of Surgeons England (RCSEng) operation note guidelines. Cases were selected at random and reviewed by a resident medical officer. Multidisciplinary staff perceptions of communication were assessed through an anonymous electronic survey across emergency departments, general practices, nursing staff, and allied health staff members from the top three population centres: Broome, Derby and Kununurra. Results: Typed operation notes with pre-loaded data (date, time, etc.) and mandatory fields (surgical count correct, etc.) increased recorded information and quality of content by 45% when compared to handwritten notes. When compared to RCSEng standards for free text, anticipated blood loss (one typed note) and abbreviation use (44 typed and 37 handwritten) showed ongoing user-dependent areas for improvement. A review of multidisciplinary staff perceptions (79 returned surveys) showed 60% of handwritten notes were seen to have a negative impact on timely post-operative care. Overall, typed notes increased legibility with a perceived improvement in acronyms/abbreviations and completeness of documentation. More than 90% of staff suggested an extension of typed notes for all surgical operations would be beneficial. Conclusion: The Kimberley region poses a unique set of challenges to the continuity of post-surgical care. This review shows typed operation notes improve legibility (100%) and increased congruence with established guidelines by 45%. It also shows a successful model for increased local and metropolitan multidisciplinary access across remote WA for timely post-operative care. In an unprecedented time where elective surgical procedures are being reduced to meet pandemic demands, now is the time to review, consider and institute practices that improve intra-operative and post-operative care.

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“…As evident from our result, 78% of the op notes were written by the registrar and junior trainees (Figure 1 ) who may not have received any formal training [ 7 , 9 ]. The vital need to incorporate learning on the ethical approach to the writing of operation notes into core surgical skills teaching for trainees has been highlighted in previous studies, and this was emphasized at our clinical governance meeting [ 10 , 11 ]. Making sure that senior surgeons review the op notes written by the junior trainees is also a useful practice worthy of consideration.…”

Section: Discussionmentioning

confidence: 99%

“…The clear advantages of using an electronic proforma are improved legibility, ease of remote access, reduced variability between different operation reports for the same procedure, convenience of tailoring the content to the recommendations of RCS, automatic coding and ease of access for research and audits [ 10 , 11 ]. Disadvantages could be in saving a form due to problem with IT, funding of hardware and software devices and the need for training and familiarisation with the system [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Improving Compliance With Operative Note Guidelines Through the Implementation of an Electronic Proforma

Oladeji¹,

Singh²,

Kastos³

2022

Cureus

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Background An operative note (op note) is a vital medical record of remarkable clinical, medico-legal and academic relevance. The Royal College of Surgeons (RCS) has set out a guideline to standardise op notes. This closed-loop audit assessed the compliance of op notes completed in our local hospital against the guidance set by RCS with the view to identify deficiencies and improve practice. Methods A retrospective review of general surgery operative notes was carried out to access their various characteristics against RCS guidance. Two additional parameters were assessed, namely, ‘cadre of the surgeon that completed the op note’ and ‘use of abbreviations’. To improve compliance with RCS guidelines, an electronic proforma (EP) that included all the 18 characteristics listed in good surgical practice was implemented and a re-audit was undertaken six months afterwards. Results A total of 200 op notes were reviewed, 98 during the initial audit cycle and 102 at the re-audit. Seventy-eight per cent (78%) of the op notes were written by trainees. At the initial audit, seven parameters performed poorly, with compliance ranging between 5.1% and 76.5%. The re-audit demonstrated improved adherence to guidelines following the implementation of the EP, as well as a reduction in the use of abbreviations. The overall compliance improved from roughly 80% to >95%. Conclusion A sustainable change was achieved through the implementation of EP with improvement demonstrated in content and structure. The need to provide teaching to trainees who are responsible for writing a vast majority of op notes was identified.

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Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

Cited by 11 publications

References 11 publications

Surgeons' perspectives on operation report documentation

Surgeons' perspectives on operation report documentation

Typed Operation Notes in Rural Western Australia: Improving Patient Care

Improving Compliance With Operative Note Guidelines Through the Implementation of an Electronic Proforma

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