A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

Abstract

IntroductionOperation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines.MethodsThis was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes.ResultsOur documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05).ConclusionThe use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.