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The quality of operation notes: can simple word processors help?
1Department of Surgery, Ealing Hospital NHS Trust, Southall, Middlesex.
Annals of the Royal College of Surgeons of England
|March 13, 1998
Summary
Computerized operation notes significantly improve legibility and quality compared to manual forms for colorectal cancer surgery. This enhancement aids in data analysis for audit and research, optimizing surgical documentation.
Area of Science:
- Medical Informatics
- Surgical Documentation
- Health Services Research
Background:
- Accurate and legible operation notes are crucial for patient care, audit, and research.
- Traditional manual methods for documenting surgical procedures can be time-consuming and difficult to read.
Purpose of the Study:
- To compare the quality of operation notes generated by different methods (proformas, word processors, templates) in patients undergoing colorectal cancer surgery.
- To assess the impact of computerized documentation on the quality and efficiency of surgical notes.
Main Methods:
- A retrospective study comparing operation notes from patients undergoing colorectal cancer surgery.
- Utilized specifically designed proformas, word processors, and predesigned templates for note generation.
- A prospective comparison was conducted after providing feedback to staff.
Main Results:
- Computerized notes, particularly those from word processors, scored higher on all quality criteria and were fully legible.
- The time taken to generate computer notes was comparable to manual methods.
- Prospective analysis showed further improvement in computer note quality, while manual note quality remained unchanged.
Conclusions:
- Word processor-based computer notes offer superior quality, legibility, and ease of amendment compared to manual forms.
- Implementation requires staff training and readily available computer hardware in operating theatres.
- Computerized systems facilitate automatic data analysis for audit and research purposes.