Title : Improving the quality of operation notes in oral and maxillofacial surgery by introducing an electronic operative note proforma
Abstract:
Introduction: The operation note is a key component of clinical documentation for patients undergoing a surgical
procedure. It provides information for continuity of care, and is important medico-legally and for audit purposes. Handwritten notes can be difficult to read, illegible and lead to delay in patient care.
The aim of this study was to evaluate the quality of operation notes in Oral and Maxillofacial Surgery
before and after the introduction of an electronic operative note proforma concordant with the Royal
College of Surgeons of England (RCS) guidelines, 2014.
Materials and Methods: A baseline audit of sixty operation notes were analysed retrospectively against the RCS criteria. We
then designed and developed a bespoke electronic operative note proforma with inclusion of clinical
coding into the existing hospital software. A prospective audit of sixty operation notes was undertaken post intervention.
Results: A hundred and twenty operation notes were included for analysis. The first cycle showed a mean 60.3% compliance to the RCS guidance. The lowest documentation was for anticipated blood loss (0%), time (32%), DVT prophylaxis (21%) and the urgency of the procedure (45%). The re-audit post intervention showed 100% compliance in all parameters.
Conclusion: Introduction of the electronic operative note proforma shows a 100% compliance to the RCS gold
standard. This has significantly improved the quality of the operation note, legibility and ultimately
patient care.
Audience Take Away:
- The audience will learn about the use of digital record keeping, how this has significantly improved the quality of operative notes and meets the criteria set by the Royal College of Surgeons England.
- The value of accurate documentation and its importance medico-legally.
- This presentation will help other Dentists to design and develop bespoke proformas to aid in documentation and record keeping.
- It will highlight the benefits of digitalisation in healthcare which helps to deliver a high standard of care to patients.
