© The Journal on Information Technology in Healthcare 2008; 6(4): 253–260
Computer Generated Operation Notes Verity Currall, Tim Chesser Department of Orthopaedics and Trauma, Frenchay Hospital, Bristol, UK.
ABSTRACT Objective: To compare the quality of handwritten operation notes with operation notes generated by a clinical information system. Design: Prospective non-randomised study. Setting: Operating theatre in a trauma unit in the United Kingdom. Methods: The Bluespier Patient Manager, a clinical information system, was introduced into an orthopaedic trauma unit and used to generate operation notes via a proforma. A four week audit of operation notes was conducted both before and after its introduction, with standards based on criteria from the Royal College of Surgeons of England, together with additional orthopaedic criteria. Results: 119 operation notes were reviewed before the introduction of computer-generated notes and 137 notes afterwards. Computer-generated notes scored more highly in all criteria except the details of the author and time of generation. Conclusion: The introduction of computer-generated operation notes has improved their quality in terms of compliance with Royal College guidelines and other orthopaedic criteria. With the advent of the National Programme for IT (NPfIT), computer generated operation notes are a logical step.
INTRODUCTION Providing an appropriate operation note is not only good practice1, it is a professional2 and legal requirement. The operation note should be legible, accompany the patient and have sufficient detail to enable continuity of care by other healthcare staff1. The last point is particularly important, due to changes in the working practices of junior staff, as a result of the European Working Time Directive. This includes ward-based (rather than firm-based) teams and shorter shifts, with more handovers. Historically, operation notes have been handwritten. This has given rise to several problems, including the use of abbreviations3, poor legibility4 and lack of description of the procedure5. These problems are faced in all surgical specialities, but orthopaedic operation notes have come in for particular criticism, having been described Correspondence and reprint requests: Verity Currall, MRCS, Department of Orthopaedics and Trauma, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK BS16 1LE. Email:
[email protected].
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Currall & Chesser as “untidy one-liners”6. This study investigates whether the use of a computerised system can improve the quality of orthopaedic trauma operation notes. METHODS The Bluespier Patient Manager (Bluespier International, Grafton Flyford, Worcestershire, United Kingdom) was introduced into the orthopaedic trauma unit at Frenchay Hospital (part of the North Bristol NHS Trust). This clinical information system is used to store outpatient and ward round notes as Word files, track inpatients and manage the trauma board and operating list. A new patient episode is created when someone is seen for the first time with a new diagnosis by selecting the patient from a list created by an interface of Bluespier with the Trust’s current Patient Administration System (PAS). Operation notes are generated via proformas, which use a combination of drop down menus (Figure 1), click boxes (Figure 2) and free text. These are converted into final operation notes as Word files (Figure 3), which are then checked, saved and printed by the author, with a paper copy placed into the patient’s notes. It is also possible to type an operation note as free text in a Word document. An extra computer workstation with intranet access, together with a printer, were required in the trauma theatre to allow the generation and printing of operation notes by the surgeon. The operative notes, along with the other documents mentioned above, can, be accessed by authorised hospital staff (generally medical
Figure 1. Screenshot showing dropdown menus from the operation note proforma
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Computer Generated Operation Notes
Figure 2. Screenshot showing click boxes from the operation note proforma
Figure 3. Screenshot showing a final operation note as a Word document The Journal on Information Technology in Healthcare 2008; 6(4): 253–260
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Currall & Chesser Table 1. Criteria for assessment of operation notes. Royal College of Surgeons Criteria
Additional Orthopaedic Criteria
Patient name, hospital number, DOB
Position
Date and time
Tourniquet time and pressure
Operating surgeon and assistant
Local anaesthetic
Consultant
DVT prophylaxis
Diagnosis
Post operative antibiotics
Procedure title
Check x-ray
Incision
Weightbearing/mobilisation
Operative findings
Removal of sutures
Procedure details
Outpatient appointment
Prostheses Closure/sutures Immediate post-operative instructions Surgeon’s signature DOB = Date of birth, DVT = Deep vein thrombosis.
and nursing staff), via a password-protected system accessible from every computer in the hospital. In addition, Bluespier has research/audit functions, which allow the system to be interrogated to find, for example, the records of all patients undergoing a specified procedure over a particular timescale. A four week prospective audit of all operation notes was conducted both before and after the introduction of Bluespier. Its use for operation notes was not compulsory, but was strongly encouraged. The audit standards were based on criteria set out by the Royal College of Surgeons of England1, as well as additional orthopaedic criteria, based partly on British Orthopaedic Association guidelines7,8 (Table 1). Most of these criteria are included in the Bluespier proformas, but prior to its introduction, operation notes were handwritten on paper with only basic prompts (patient details, procedure and indication). Data were collected from the paper operative notes - whether written or computer-generated - in the patients’ medical records. Tick box proformas for the presence or absence of the criteria described above were filled in by the first author, bearing in mind that not all criteria would be applicable to every procedure. The use of a tourniquet and/or local anaesthetic was cross-checked with the nursing record. RESULTS One hundred and nineteen operation notes were reviewed before the introduction of computer-generated notes and 137 notes afterwards. Of these, 116 (85%) were generated via computer and 21 (15%) were handwritten.
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Computer Generated Operation Notes
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Figure 4. Comparison between pre- and post-Bluespier results DOB = Date of birth; OPA = Outpatient appointment; Local = Local anaesthetic; ROS = Removal of sutures.
In the notes from before the introduction of Bluespier, the criteria were generally met, but the documentation of tourniquet (pressure 17/33 = 52%; time 24/33 = 73%) and local anaesthetic (14/24 = 58%) use intraoperatively were poor. This was also the case for postoperative instructions, including check x-ray (67/85 = 79%), outpatient appointment (73/97 = 75%), suture removal (60/81 = 74%) and postoperative antibiotics (35/78 = 45%). From a graphical comparison between the two sets of results (Figure 4), it can be seen that there were large differences in some of the criteria. For these criteria, the post-Bluespier notes results were also divided into those operation notes generated using the computer and those which were still handwritten and the comparisons are summarised in Table 2. Of the criteria where the post-computer notes scored more highly than the precomputer notes, most (including general details, operative details and post-operative instructions) did so because the computer-generated notes were of a higher quality (i.e. had higher scores on the criteria). The post-Bluespier written notes had similar scores to the pre-Bluespier notes. There were, however, a few exceptions. The documentation of local anaesthetic and tourniquet use was much better in the post-Bluespier notes, but this improveThe Journal on Information Technology in Healthcare 2008; 6(4): 253–260
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Currall & Chesser Table 2. Summary of differences between quality of operation notes, from pre- and post-Bluespier notes, both written and computer-generated Post Bluespier %
Pre Bluespier
Total
Bluespier
Written
Consultant
81
97
100
81
DOB
84
96
100
76
Description
99
97
99
86
Findings
80
96
98
81
Prosthesis
96
94
97
70
Position
77
90
92
79
Local anaesthetic
58
85
85
86
Tourniquet time
73
89
90
83
Tourniquet pressure
52
87
86
100
Tourniquet not mentioned
24
9
10
0
Weightbearing status
83
95
96
88
Prophylactic antibiotics
45
87
95
55
OPA
75
87
91
65
X-ray
79
76
78
65
Signature
98
12
0
76
Designation
88
11
0
71
Author Name
20
5
0
33
Time
47
9
0
57
DOB = Date of birth; OPA = Outpatient appointment.
ment took place in both the computer-generated and written notes. There is no obvious explanation for this, although both criteria scored particularly badly before the introduction of computer-generated notes. The only areas in which the computer-generated notes were worse than the handwritten notes were in the details of the author (name, designation and signature) and time of day, none of which are routinely contained in the computer-generated notes. With the exception of the signature, however, the other details are available from a separate audit trail function of the system. DISCUSSION Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results4,5. Several solutions to the problem have previously been tried. The use of an aide-memoire in theatre has improved the quality of notes in ENT departments, in terms of patient details and abbreviations3, as well as
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Computer Generated Operation Notes adherence to Royal College guidelines9. The introduction of a proforma in trauma and orthopaedic surgery has significantly improved the documentation of several criteria, including patient hospital number, consultant, diagnosis, position and the use of tourniquets and antibiotics10. With the advent of the National Programme for IT (NPfIT), computer generated operation notes are a logical step. A computerised template with drop-down menus and free text has proved better than handwritten notes in ENT emergency clinics11. An early database management system for general surgery was effective in collecting data and allowed the generation of operation notes, but their quality was not investigated12. In another study, operation notes produced by a word processor using predesigned templates scored more highly than written notes using a proforma13. Our results show that the quality of the operation notes in most criteria improved after the introduction of computer-generated operation notes as part of the Bluespier clinical information system. Apart from the documentation of local anaesthetic and tourniquet use, the quality of written notes had not improved over the same period, so it is reasonable to attribute the change to the use of computer-generated operation notes. The main deficiency was the lack of signature on the final printed operation note, but should be easy to remedy with education or the use of electronic signatures. Although ease and speed of use were not specifically investigated in this study, the general impression of the users was that the system is easy to use, although some of the proformas need minor alterations. It initially takes a few minutes more to produce a computer-generated note than a written one, but this decreases with familiarity and the use of personal default settings. There are also considerable time savings when needing to check an operation note if the paper notes are not readily available (for example, when a patient is readmitted or the notes have been lost before an outpatient appointment). In addition, audit and log book generation is easily achievable. The NHS Care Records Service will take several years to fully implement, but will eventually allow clinicians to access linked records from every NHS organisation used by a patient (from both primary and secondary care), with details of all investigations and treatment, including operation records14. The Bluespier system achieves this in terms of operation notes, as well as ward round and outpatient notes. Development will soon allow interface with PACS (Picture Archiving and Communication System) and laboratory investigations to allow a fully integrated system. Currently, 16 hospitals in the United Kingdom and Ireland (including ours) are using the Bluespier system15. In conclusion, the introduction of computer-generated operation notes has improved their quality in terms of compliance with both Royal College criteria and other orthopaedic criteria.
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