‘Smart’ electronic operation notes in surgery: An innovative way to improve patient care

Ghani, Yaser; Thakrar, Raj; Kosuge, Dennis; Bates, Peter

doi:10.1016/j.ijsu.2013.10.017

Cited by 47 publications

(39 citation statements)

References 3 publications

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“…All of the typed notes were legible; this corresponds with the results presented by Ghani, et al [14]. They found a major difference in the legibility between handwritten (66% legible) versus typed notes (100% legible) [14].…”

Section: Discussionsupporting

confidence: 86%

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Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Coughlan

Ellanti

Moriarty

et al. 2017

Cureus

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IntroductionThe Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet.ObjectivesTo retrospectively audit 57 typed orthopaedic operation notes from St. James’s Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department’s previous audit of handwritten notes to complete the audit loop.Materials and methodsA total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James’s Hospital operation note proforma.ResultsOf the surgeries, 89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible.ConclusionThe use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.

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Section: Discussionsupporting

confidence: 86%

“…They found a major difference in the legibility between handwritten (66% legible) versus typed notes (100% legible) [14]. Of the notes reviewed for this paper, 86% of the handwritten notes from our previous audit were deemed legible by our three independent reviewers.…”

Section: Discussionmentioning

confidence: 99%

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Coughlan

Ellanti

Moriarty

et al. 2017

Cureus

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“…[41-45] Each article reported either a retrospective or prospective observational study consisting of sample sizes with less than 200 notes in each arm. All studies showed greatly improved inclusion of crucial information, such as closure details, anesthesia, and antibiotics in electronically generated notes.…”

Section: Resultsmentioning

confidence: 99%

“…[45] Four of the studies reported a significant decrease in the time to finalization of electronic notes, with electronic notes being completed in 0.115. − 0.5 days compared to 5.8 −20.7 days for dictated notes.…”

Section: Resultsmentioning

confidence: 99%

Review of information technology for surgical patient care

Robinson

Huth

Jackson

2016

Journal of Surgical Research

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Introduction Electronic health records (EHRs), computerized order entry (CPOE), and patient portals have experienced increased adoption by healthcare systems. The objective of this study was to review evidence regarding the impact of such health information technologies (HIT) on surgical practice. Materials and Methods A search of Medline, EMBASE, CINAHL, and the Cochrane Library was performed to identify data-driven, non-survey studies about the effects of HIT on surgical care. Domain experts were queried for relevant articles. Two authors independently reviewed abstracts for inclusion criteria and analyzed full-text of eligible articles. Results 2890 citations were identified. 32 observational studies and 2 RCTs met eligibility criteria. EHR or CPOE improved appropriate antibiotic administration for surgical procedures in 13 comparative observational studies. 5 comparative observational studies indicated electronically generated operative notes had increased accuracy, completeness, and availability in the medical record. The Internet as an information resource about surgical procedures was generally inadequate. Surgical patients and providers demonstrated rapid adoption of patient portals, with increasing proportions of online versus in-person outpatient surgical encounters. Conclusion The overall quality of evidence about the effects of HIT in surgical practice was low. Current data suggest an improvement in appropriate perioperative antibiotic administration and accuracy of operative reports from CPOE and EHR applications. Online consumer health educational resources and patient portals are popular among patients and families, but their impact has not been studied well in surgical populations. With increasing adoption of HIT, further research is needed to optimize the efficacy of such tools in surgical care.

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“…This highlights the need for improved database, electronic medical record systems and standardized operative note templates. Implementation of an electronic operation note system could help resolve this problem [8]. There is evidence of the superiority of computerized operation notes over hand written notes [9].…”

Section: Discussionmentioning

confidence: 99%

Comprehensive Operative Note Templates for Primary and Revision Total Hip and Knee Arthroplasty

Electricwala

Amanatullah

Narkbunnam

et al. 2016

TOORTHJ

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Background:Adequate preoperative planning is the first and most crucial step in the successful completion of a revision total joint arthroplasty. The purpose of this study was to evaluate the availability, adequacy and accuracy of operative notes of primary surgeries in patients requiring subsequent revision and to construct comprehensive templates of minimum necessary information required in the operative notes to further simplify re-operations, if they should become necessary.Methods:The operative notes of 144 patients (80 revision THA’s and 64 revision TKA’s) who underwent revision total joint arthroplasty at Stanford Hospital and Clinics in the year 2013 were reviewed. We assessed the availability of operative notes and implant stickers prior to revision total joint arthroplasty. The availability of implant details within the operative notes was assessed against the available surgical stickers for adequacy and accuracy. Statistical comparisons were made using the Fischer-exact test and a P-value of less than 0.05 was considered statistically significant.Results:The primary operative note was available in 68 of 144 revisions (47%), 39 of 80 revision THAs (49%) and 29 of 66 revision TKAs (44%, p = 0.619). Primary implant stickers were available in 46 of 144 revisions (32%), 26 of 80 revision THAs (32%) and 20 of 66 revision TKAs (30%, p = 0.859). Utilizing the operative notes and implant stickers combined identified accurate primary implant details in only 40 of the 80 revision THAs (50%) and 34 of all 66 revision TKAs (52%, p = 0.870).Conclusion:Operative notes are often unavailable or fail to provide the necessary information required which makes planning and execution of revision hip and knee athroplasty difficult. This emphasizes the need for enhancing the quality of operative notes and records of patient information. Based on this information, we provide comprehensive operative note templates for primary and revision total hip and knee arthroplasty.

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‘Smart’ electronic operation notes in surgery: An innovative way to improve patient care

Cited by 47 publications

References 3 publications

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Review of information technology for surgical patient care

Comprehensive Operative Note Templates for Primary and Revision Total Hip and Knee Arthroplasty

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