The quality of operation notes: can simple word processors help?
In a retrospective study the quality of operation notes on specifically designed proformas was compared to those produced by word processors and predesigned templates and notes in patients undergoing operations for colorectal cancer. The operations in the two groups were similar. Computer notes scored higher on all criteria, were all legible and took the same time to generate. The results were given to staff in an attempt to improve the quality of future notes. Prospective comparison demonstrated that the quality of computer notes improved even further, while that of manual forms did not change. Word processor computer notes are easy to set up, amend and produce but staff should be trained in the use of personal computers and machines must be readily available in operating theatres. Word processor databases will, in addition, enable the data collected to be analysed automatically to yield information for audit and research.
O'Bichere
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Department of Surgery, Ealing Hospital NHS Trust, Southall, Middlesex.
Sellu
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D015179:Colorectal Neoplasms / Q000601:surgery; D004739:England; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000592:standards; D016347:Medical Records Systems, Computerized / Q000592:standards*; D011446:Prospective Studies; D011786:Quality Control; D012189:Retrospective Studies; D013503:Surgery Department, Hospital / Q000458:organization & administration* / Q000592:standards; D015443:Word Processing / Q000592:standards*