title: Improving the quality of procedure-specific operation reports in orthopaedic surgery.
abstract: BACKGROUND
  The objectives of this study were to: (i) assess whether handwritten operation reports for hip hemi-arthroplasties adhere to The Royal College of Surgeons of England (RCSE) guidelines on surgical documentation; (ii) improve adherence to these guidelines with procedure-specific computerised operation reports; and (iii) improve the quality of documentation in surgery.
  
  
  METHODS
  Thirty-three parameters based on RCSE guidelines were used to score hip hemi-arthroplasty operation reports. The first audit cycle was performed retrospectively to assess 50 handwritten operation reports, and the second cycle prospectively to assess 30 new computerised procedure-specific operation reports produced for hip hemi-arthroplasties. Eighty patients undergoing hip hemi-arthroplasty in a department of orthopaedic surgery within a UK hospital between September 2007 and August 2008 formed the study cohort.
  
  
  RESULTS
  The main outcome measure was the average scores attained by handwritten versus computerised operation reports. Handwritten reports scored an average of 58.7%, rising significantly (P < 0.01) to 92.8% following the introduction of detailed, computerised proformas for the operation note. Adherence to each RCSE parameter was improved.
  
  
  CONCLUSIONS
  Computerised proformas reduce variability between different operation reports for the same procedure and increase their content in line with RCSE recommendations. The proformas also constitute a more robust means of operative documentation.
authors.affiliation: Department of Orthopaedic Surgery, Kent and Sussex Hospital, Tunbridge Wells, Kent, UK. awb@doctors.org.uk
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Barritt
authors.forename: Laura
authors.initials: L
authors.lastname: Clark
authors.forename: Adam M M
authors.initials: AM
authors.lastname: Cohen
authors.forename: Naveen
authors.initials: N
authors.lastname: Hosangadi-Jayedev
authors.forename: Paul A
authors.initials: PA
authors.lastname: Gibb
mesh_terms: D019644:Arthroplasty, Replacement, Hip; D004739:England; D019983:Guideline Adherence; D006236:Handwriting; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care