Use of database management system by surgeons to produce operation notes

Area of Science:

• Medical Informatics
• Surgical Technology

Background:

• Traditional methods of generating operative records are time-consuming and can lead to illegible documentation.
• Lack of standardized data collection hinders audit, research, and trainee education.

Purpose of the Study:

• To describe a computer system for real-time generation of operative records within the operating suite.
• To evaluate the system's impact on efficiency, data quality, and potential for secondary use of information.

Main Methods:

• Development and implementation of a surgeon-operated computer system for operative record generation.
• Inclusion of mandatory fields to enforce structured data entry compliant with Royal College of Surgeons guidelines.
• Evaluation of time required for record generation and its impact on operating list flow.

Main Results:

• The system generates legible operative records in approximately 4-6 minutes, without disrupting surgical procedures.
• Automatic OPCS coding and grading are achieved, alongside data storage for audit and research purposes.
• The system facilitates the creation of an operating log for surgical trainees.

Conclusions:

• The computer system streamlines operative record creation, enhancing legibility and data standardization.
• It offers significant benefits for clinical audit, research, trainee education, and potentially discharge documentation.
• The system promotes adherence to medical record guidelines, improving overall documentation quality and efficiency.