Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures

Abstract Objectives The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck o...

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Main Authors: Fraser Sneddon, N. Fritsch, S. Mackenzie, D. Skipsey, I. A. Rankin
Format: Article
Language:English
Published: BMC 2023-01-01
Series:Journal of Orthopaedic Surgery and Research
Online Access:https://doi.org/10.1186/s13018-022-03484-9
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author Fraser Sneddon
N. Fritsch
S. Mackenzie
D. Skipsey
I. A. Rankin
author_facet Fraser Sneddon
N. Fritsch
S. Mackenzie
D. Skipsey
I. A. Rankin
author_sort Fraser Sneddon
collection DOAJ
description Abstract Objectives The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes. Methods A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes. Results Ninety-seven cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the freehand op-note group (templated median 14, range 12–14, vs. freehand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by consultants or trainees identified trainees as more likely to document the antibiotic prophylaxis given (p = 0.025). Conclusions Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.
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spelling doaj.art-235191d41f25429d9b9b515a4958f31b2023-01-22T12:20:00ZengBMCJournal of Orthopaedic Surgery and Research1749-799X2023-01-011811410.1186/s13018-022-03484-9Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical proceduresFraser Sneddon0N. Fritsch1S. Mackenzie2D. Skipsey3I. A. Rankin4Department of Trauma and Orthopaedics, NHS HighlandDepartment of Trauma and Orthopaedics, NHS HighlandDepartment of Trauma and Orthopaedics, NHS TaysideDepartment of Trauma and Orthopaedics, NHS GrampianDepartment of Trauma and Orthopaedics, NHS GrampianAbstract Objectives The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes. Methods A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes. Results Ninety-seven cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the freehand op-note group (templated median 14, range 12–14, vs. freehand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by consultants or trainees identified trainees as more likely to document the antibiotic prophylaxis given (p = 0.025). Conclusions Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.https://doi.org/10.1186/s13018-022-03484-9
spellingShingle Fraser Sneddon
N. Fritsch
S. Mackenzie
D. Skipsey
I. A. Rankin
Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures
Journal of Orthopaedic Surgery and Research
title Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures
title_full Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures
title_fullStr Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures
title_full_unstemmed Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures
title_short Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures
title_sort orthopaedic surgical documentation pre templated operation notes significantly improve documentation of surgical procedures
url https://doi.org/10.1186/s13018-022-03484-9
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