A cross-sectional retrospective study comparing handwritten operation notes with electronic operation notes.

Area of Science:

• Medical Informatics
• Surgical Practice
• Health Information Management

Background:

• Handwritten operation notes persist despite evidence favoring electronic records for legibility and completeness.
• Surgeons continue to rely on traditional handwritten notes for patient documentation.
• A gap exists between the recognized benefits of electronic notes and their clinical adoption.

Purpose of the Study:

• To compare the quality of handwritten versus electronic operation notes.
• To assess legibility and completeness against established surgical practice standards.
• To provide evidence for optimizing surgical documentation methods.

Main Methods:

• Retrospective, cross-sectional study of 405 general surgery operation notes.
• Evaluation based on 18 criteria from the Royal College of Surgeons of England's Good Surgical Practice guidelines.
• Data collation via app and analysis using SPSS, presented with bar graphs and frequency tables.

Main Results:

• Electronic notes demonstrated superior completeness in 17 out of 18 criteria (p<0.001).
• Illegibility was present in 8.3% of handwritten notes, with none recorded for electronic notes.
• Signature completeness was comparable (95% handwritten vs. 91% electronic).

Conclusions:

• Electronic operation notes are significantly better than handwritten notes across most quality criteria.
• The substantial differences support a complete transition from handwritten to electronic surgical notes.
• Adoption of electronic systems is crucial for enhancing the quality and reliability of surgical documentation.