WTP6.7 Implementation of a Trust-wide electronic operation note proforma – a quality improvement project

Abstract

Abstract Aims The operation note is an important document that records intra-operative details and provides post-operative instructions. It ensures continuity of care and may be used for medicolegal purposes. In our Trust, there is a move towards electronic operation notes in line with the digitisation of patient records. Here we report initial data from our multi-staged implementation of a Trust-wide electronic operation note proforma. Method The Plan/Do/Study/Act (PDSA) method was used. Regular key stakeholder meetings were held involving the Information Technology (IT) department and various surgical teams. The Royal College of Surgeons’ Good Surgical Practice (GSP) provided minimum standards for operation notes. Forms4Health was used as the platform for electronic operation notes. In PDSA cycle 1, a retrospective audit was performed involving 50 randomly selected handwritten or typed operation notes. The operation notes were audited by two independent reviewers against GSP standards. Handwritten operation notes were also assessed for legibility. Results A total of 29 handwritten and 21 typed operation notes were analysed. Among the handwritten operation notes, 15 (52%) were legible. Handwritten notes demonstrated 68% compliance with GSP standards, as compared to 79% for typed notes (p <0.05). Typed notes were superior at recording time of surgery (p <0.01), whether it was elective or emergency (p <0.01), complications encountered (p <0.05) and thromboprophylaxis instructions (p <0.01). Conclusions Our data indicate a significant improvement in GSP compliance via electronic notes. As next steps, we will integrate the proforma into existing Trust IT platforms and include additional features to increase user efficiency and re-audit service improvement.