title: Use of database management system by surgeons to produce operation notes.
abstract: A computer system for the generation of printed operation records based in the operating suite and used by the surgeon is described. The time necessary for producing such a record is in the order of 4-6 minutes for the majority of cases and does not interfere with the conduct of an operating list. The advantages include a printed legible operative record, automatic OPCS coding and automatic grading, the storage of data in a form that allows later analysis for audit and research and the production of an operating log for trainees. The use of mandatory fields forced individuals to follow a structured format complying with the guidelines on medical records and notes from The Royal College of Surgeons of England reissued in 1994. The potential value of using the same data for the production of discharge documentation suggests an opportunity for improving the efficiency in the production of such documentation.
authors.affiliation: Derriford Hospital, Plymouth.
authors.forename: R F
authors.initials: RF
authors.lastname: Dale
authors.forename: M J
authors.initials: MJ
authors.lastname: Midwinter
mesh_terms: D003628:Database Management Systems; D013502:General Surgery / Q000458:organization & administration*; D006801:Humans; D008485:Medical Audit / Q000379:methods; D016347:Medical Records Systems, Computerized; D013997:Time Factors; D018875:Vocabulary, Controlled