Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures

Autor: Fraser Sneddon, N. Fritsch, S. Mackenzie, D. Skipsey, I. A. Rankin
Jazyk: angličtina
Rok vydání: 2023
Předmět:
Zdroj: Journal of Orthopaedic Surgery and Research, Vol 18, Iss 1, Pp 1-4 (2023)
Druh dokumentu: article
ISSN: 1749-799X
DOI: 10.1186/s13018-022-03484-9
Popis: Abstract Objectives The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes. Methods A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes. Results Ninety-seven cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p
Databáze: Directory of Open Access Journals
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