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

Fitzgerald Anazor1, Vusumuzi Sibanda1, Aisha Abubakar1

  • 1Trauma and Orthopaedics, William Harvey Hospital, Ashford, GBR.

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|August 16, 2022
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Summary
This summary is machine-generated.

Implementing typed operation note templates significantly improved documentation quality in orthopedic trauma surgery. This enhances patient safety and clinical communication by ensuring clearer, more accurate surgical records.

Keywords:
audit and feedbackmedical recordsoperation notesquality improvementtrauma and orthopedic surgery

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Area of Science:

  • Medical Auditing
  • Surgical Quality Improvement
  • Orthopedic Trauma Care

Background:

  • Operation notes are critical for patient safety, inter-clinician communication, and medicolegal documentation.
  • Ensuring clarity and accuracy in operation notes is paramount for effective healthcare delivery.
  • The Royal College of Surgeons (RCS) of England provides guidelines for good surgical practice.

Purpose of the Study:

  • To audit and improve the quality of operation notes in orthopedic trauma surgery.
  • To assess the impact of implementing typed operation note templates on documentation standards.
  • To identify specific areas of improvement in surgical record-keeping.

Main Methods:

  • A prospective audit of 99 orthopedic trauma operation notes was conducted in two cycles.
  • Seventeen parameters were audited per note against RCS guidelines.
  • Changes implemented included the introduction of a typed operation note template, followed by a re-audit.

Main Results:

  • Documentation quality improved for 12 out of 17 audited parameters post-intervention.
  • Significant improvements were observed in recording indication for surgery, tourniquet time, antibiotic prophylaxis, closure technique, and postoperative instructions.
  • While typed notes showed higher compliance (25% achieved 100% compliance), no statistically significant difference in the mean number of correctly documented parameters was found between typed and handwritten notes.

Conclusions:

  • Operation note templates, particularly typed versions, can enhance documentation in orthopedic trauma surgery.
  • Making standardized, adaptable templates accessible to surgeons is recommended.
  • Adoption of such templates can lead to better patient safety and communication in orthopedic trauma units.