Matthew Howard1, Hammad Parwaiz2, Emily Cassels3, Natalie Smith3, Lucy Howard4. 1. Core Surgical Trainee, Department of Surgery, Royal United Hospital Bath NHS Trust, Bath BA1 3NG. 2. Core Surgical Trainee, Department of Surgery, Royal United Hospital Bath NHS Trust, Bath. 3. Foundation Doctor, Department of Surgery, Royal United Hospital Bath NHS Trust, Bath. 4. Clinical Fellow, Department of Surgery, Royal United Hospital Bath NHS Trust, Bath.
Abstract
INTRODUCTION: Operation notes are often poorly completed, potentially compromising patient care. This project was undertaken to improve the quantity, quality and clarity of information included in operation notes, and make them easier to locate within a set of patient notes. METHODS: Operation notes were audited against standards laid out in national guidelines. The time taken for staff to locate an operation note, and information within it, was then measured. The layout was re-designed, followed by a re-audit. RESULTS: The number of operation notes with all measured domains completed rose from 4% to 34% (P<0.001). The mean time to locate the operation note fell from 30 to 4 seconds, and the mean time to locate all requested pieces of information within the operation note fell from 35 to 20 seconds. CONCLUSIONS: The interventions have improved quality and speed of access of operation notes, but there is still room for improvement.
INTRODUCTION: Operation notes are often poorly completed, potentially compromising patient care. This project was undertaken to improve the quantity, quality and clarity of information included in operation notes, and make them easier to locate within a set of patient notes. METHODS: Operation notes were audited against standards laid out in national guidelines. The time taken for staff to locate an operation note, and information within it, was then measured. The layout was re-designed, followed by a re-audit. RESULTS: The number of operation notes with all measured domains completed rose from 4% to 34% (P<0.001). The mean time to locate the operation note fell from 30 to 4 seconds, and the mean time to locate all requested pieces of information within the operation note fell from 35 to 20 seconds. CONCLUSIONS: The interventions have improved quality and speed of access of operation notes, but there is still room for improvement.
Authors: M Berlet; T Vogel; D Ostler; T Czempiel; M Kähler; S Brunner; H Feussner; D Wilhelm; M Kranzfelder Journal: Int J Comput Assist Radiol Surg Date: 2022-05-28 Impact factor: 3.421