A Clinical Audit of Orthopaedic Operation Note Documentation and Digitalization of the Operative Note Template: A...

Background Good communication between a surgical team and other colleagues is vital, and the medium of communication is often the operative note. It is essential to ensure continuity of care between the operating team and other colleagues; also, it provides a medicolegal record of patient care. It checks all the four main domains of good surgical practice guidelines set by the Royal College of Surgeons (RCS) of England. The aims of this project were to evaluate the quality of operation notes against the set parameters by the RCS and to improve quality of the operative notes using information technology (IT) service software update to provide operative note digitalization. Methods This was a retrospective and prospective closed-loop audit, in which the operative notes were analysed for the Trauma and Orthopaedics speciality. Three separate cycles of audits were completed. In the the first cycle, data were collected retrospectively from all the operative notes, from June 1, 2020, to June 15, 2020; then, data were collected prospectively after making interventions to establish digitalization of the operative notes. The second cycle was completed from February 14 to 21, 2021, and from March 1 to 7, 2021. The third cycle was completed from August 1 to 31, 2021. All data were collected in Excel using a checklist that evaluated 34 parameters. These parameters were based on the recommendations of RCS Good Surgical Practice guidelines. All trauma and orthopaedic patients were included regardless of the type of procedure. There were no exclusion criteria in place. Results An overall increase from 9.5% to 66.7% in typed operative notes was achieved with the introduction of the templated operative note documentation service. There was a 40% reduction in the use of handwritten operative notes. Concerns regarding legibility were reduced in view of the digitalization of the operative notes. The first cycle of the audit, in terms of the parameters yielded, found that the operative notes were missing 10 important parameters, independent of the author grade; these were recorded in less than 10% of the operative notes. The second cycle, in terms of the parameters yielded, found that the operative notes were missing four important parameters, independent of the author grade; these were recorded in less than 10% of the operative notes. The third cycle of the audit, in terms of the parameters yielded, found that the operative notes were missing three important parameters. Specific documentation for 12 different parameters improved over the course of the three Plan-Do-Study-Act (PDSA) cycles. Conclusion Royal College of Surgeons guidelines and integration with IT services significantly improved the quality and legibility of operative notes that were being documented in the trauma and orthopaedics department. Structured document standards and good integration with a computer-based IT service help prompt surgeons to document in a better and easy way, thereby leading to improved clinical documentation.