Abstract
Introduction
Quality operation note documentation is essential for ensuring continuity of care amongst the multi-disciplinary team. The Royal College of Surgeons has published clear and succinct guidelines which outline the necessity for timely, accurate and accessible operation note documentation. Our department uses a bespoke electronic operation note template which is stored within a departmental database. The aim of this study was to evaluate the effect of online operation note guidance on the accessibility of operative documentation.
Method
A prospective audit of operation note documentation was conducted during two one-month periods in May and November 2018. All reconstructive surgical procedures, both trauma and elective, were included. A bespoke online reminder system was introduced to our electronic platform to encourage operation note upload onto electronic medical records.
Result
224 cases (127 elective, 98 consultant-led) were included in the initial audit and 239 cases (173 elective, 131 consultant-led) in the post-intervention audit. 56% of operation notes were accessible to nursing staff pre-intervention. Post-intervention 83% of operation notes were accessible to nursing staff (p< 0.05). No significant correlation was found between operation note accessibility and the type of case (elective vs emergency, r= -0.179), grade of operating surgeon (consultant vs registrar, r=0.259) and the number of operating surgeons (r=0.208).
Conclusion
This study highlights the importance of operation note accessibility to every member of the multidisciplinary team. A pop-up based intervention significantly improved accessibility of operation notes within electronic medical records although performance remains significantly below the expected standard.
Take-home message
The use of bespoke, online platforms may limit access to operation notes. A simple, pop-up based intervention significantly improves upload rate to electronic medical records however accessibility remains significantly below the expected standard.
P17: IMPROVING PLASTIC SURGERY OPERATION NOTE ACCESSABILITY AT A MAJOR TRAUMA CENTRE: A PROSPECTIVE COMPLETED AUDIT CYCLE