Khalid Al-Dadah1, Owain Evans2, Fazal Ali3. 1. Core Surgical Trainee in the Department of Trauma and Orthopaedic Surgery, University College London Hospital, London NW1 2BU. 2. Specialist Registrar in the Department of Trauma and Orthopaedic Surgery, Northern General Hospital, Sheffield. 3. Consultant in the Department of Trauma and Orthopaedic Surgery, Chesterfield Royal Hospital, Chesterfield.
Abstract
INTRODUCTION: The purpose of the study was to assess the quality of documentation of knee arthroscopy and evaluate the implementation of a novel operative template. METHOD: A 34-point assessment was undertaken based on published national guidelines. A retrospective study of 50 operative notes of patients (group A) undergoing knee arthroscopy was completed. A new operative note template was devised to include important criteria and assessed in 49 patients (group B) for its efficacy in providing appropriately detailed findings. RESULTS: Group A was lacking the minimum essential documentation standards expected. Some essential criteria for arthroscopic procedures were as low as 4%. Group B showed a statistically significant increase (P<0.001) in documentation accuracy throughout the essential criteria compared to the findings in group A. CONCLUSIONS: The authors conclude that the use of an evidence-based operative template for knee arthroscopy significantly improves the quality and accuracy of documentation compared to conventional free-hand operative notes.
INTRODUCTION: The purpose of the study was to assess the quality of documentation of knee arthroscopy and evaluate the implementation of a novel operative template. METHOD: A 34-point assessment was undertaken based on published national guidelines. A retrospective study of 50 operative notes of patients (group A) undergoing knee arthroscopy was completed. A new operative note template was devised to include important criteria and assessed in 49 patients (group B) for its efficacy in providing appropriately detailed findings. RESULTS: Group A was lacking the minimum essential documentation standards expected. Some essential criteria for arthroscopic procedures were as low as 4%. Group B showed a statistically significant increase (P<0.001) in documentation accuracy throughout the essential criteria compared to the findings in group A. CONCLUSIONS: The authors conclude that the use of an evidence-based operative template for knee arthroscopy significantly improves the quality and accuracy of documentation compared to conventional free-hand operative notes.