Computer generated operation notes.
Providing an appropriate operation note is not only good practice, it is a professional and legal requirement. It was therefore necessary to ascertain whether operation notes generated by a clinical information system were of acceptable quality compared to handwritten notes when the Bluespier Patient Manager, a clinical information system, was introduced into an orthopaedic trauma unit. A four week prospective audit of operation notes was conducted both before and after its introduction, with standards based on criteria from the Royal College of Surgeons of England, plus additional orthopaedic criteria. 119 operation notes were reviewed before the introduction of computer-generated notes and 137 notes afterwards. Computer-generated notes were of better quality in all areas except the details of the author and time of generation. Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results and several solutions have previously been tried. With the advent of the National Programme for IT (NPfIT), computer generated notes are the next logical step. The introduction of computer-generated operation notes has improved their quality in terms of compliance with Royal College guidelines and other orthopaedic criteria.
Department of Trauma and Orthopaedics, Frenchay Hospital, Bristol, UK. verity_currall@hotmail.com
V A
VA
Currall
T J
TJ
Chesser
D004739:England; D005568:Forms and Records Control; D006801:Humans; D008485:Medical Audit; D016347:Medical Records Systems, Computerized / Q000592:standards; D008501:Medical Records, Problem-Oriented / Q000592:standards; D019637:Orthopedic Procedures / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011787:Quality of Health Care