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Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma
Injury, Int. J. Care Injured (2004) 35, 1102—1106
Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma H. Al Hussainya,c,*, F. Alib, S. Jonesb, J.C. McGregor-Rileyb, S. Sukumard a
Department of Orthopaedic & Trauma Surgery, University of Sheffield, Sheffield, England, UK Department of Orthopaedic and Trauma Surgery, Northern General Hospital, Sheffield, England, UK c Department of Orthopaedic & Trauma Surgery, Chesterfield and North Derbyshire Royal Hospital, Calow, Chesterfield, England, UK d Department of Orthopaedic and Trauma Surgery, Rotherham General Hospital, Rotherham, England, UK b
Accepted 1 October 2003
KEYWORDS Trauma surgery; Orthopaedic surgery; Operation note; Proforma
Summary Comprehensive documentation of surgical procedures is an essential component of good medical practice, but the standard of operation notes in orthopaedic and trauma surgery has been notoriously poor. The value of proformas in the production of high standard operation notes has been demonstrated in various surgical specialities. We have compared the standard of documentation of operation notes before and after the introduction of a proforma and report a significant improvement (P < 0:001) with the proforma. In addition, the results from a neighbouring hospital where a similar proforma was in use show a sustained standard of documentation 5 years after it was first used. ß 2003 Elsevier Ltd. All rights reserved.
Introduction An operation note is one of the means of communication between health care professionals and has a great impact on structuring a management plan post-operatively. It is the only legal record of the surgery performed, and like all legal documents it should be legible, dated, and contain pertinent information. The General Medical Council states that proper note keeping is an essential component of good medical practice.9 Despite this, the standard of operation notes in orthopaedic surgery is poor and the National Confidential Enquiry Into Peri*Corresponding author. Tel.: þ44-7931-811213. E-mail address: [email protected] (H. Al Hussainy).
Operative Death (NCEPOD) report of 1992—1993, described many orthopaedic notes as ‘‘. . . untidy one liners’’.4 Dictated notes, computer generated notes, and the use of a proforma are being used in an attempt to improve the standard of operation notes. The usefulness of a proforma in the disciplines of general surgery,8 and otorhinolaryngology3 has been shown in previous reports. This study examines the value of a proforma in improving the standard of operation notes in orthopaedic and trauma surgery.
Materials and methods Between January and July 1999, a review of the standard of operation notes in the Orthopaedic
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.016
Improving the standard of operation notes in orthopaedic and trauma surgery
Department of the Chesterfield and North Derbyshire Royal Hospital was undertaken. One thousand nine hundred and twenty-eight orthopaedic and trauma operation notes were identified from the operating theatre logbooks. The procedures of manipulation under anaesthetic, injection of steroid, and caudal epidural were excluded. Eightyeight case notes were randomly selected by computer and the operation notes were assessed by a single observer to determine if the notes met
Figure 1
1103
guidelines as stated by the Royal College of Surgeons10 (Table 1). Additional criteria relevant to orthopaedic and trauma surgery were also assessed (Table 2). An operation note proforma was devised (Fig. 1). It was used over a trial period of 2 weeks to determine its practicality, and then subsequently used routinely for all operations over a period of 8 weeks. Five hundred and ninety operation note proformas were used over the 8-week study period. Seventy-nine
The operation note proforma.
1104
H. Al Hussainy et al.
Table 1 shows the operation notes standard criteria as set by the Royal College of Surgeons of England
Table 2 shows the additional orthopaedic criteria used in the proforma
Royal College of Surgeons Guidelines Criteria
Additional orthopaedic criteria
Name of patient Identification number Consultant Operating surgeon Name of anaesthetist Method of anaesthesia Diagnosis Operation title Findings Procedure Prosthesis details Sutures used Intra-operative complications Post-operative instructions Signature
Date Position Approach Antibiotics given Use of tourniquet Drains Legibility
of these were then randomly selected for analysis. We then randomly selected 70 operation notes from a nearby District General Hospital in which a proforma had been in use for 5 years. A single observer reviewed these notes to determine if they met the Royal College guidelines (as above).
Plates 1 and 2 The inclusion percentages of the criteria (as set by the Royal College of Surgeons of England and the additional orthopaedic criteria) with and without the operation note proforma.
Improving the standard of operation notes in orthopaedic and trauma surgery
The results obtained before and after the proforma was introduced in our hospital were compared and analysed statistically using the Wilcoxon signed rank test. We compared our results (using the proforma) with the results from the neighbouring hospital.
Results Before the introduction of the proforma, the date, the operation title, procedure, method of closure of the surgical wound, the surgeon’s name, and signature were well documented. The details of patient ID number, pre-operative diagnosis, use of prophylactic antibiotics, position of the patient, and record of intra-operative complications were poorly documented (less than 35% of patients) (Plates 1 and 2). Following the introduction of the proforma in our unit, there was a statistically significant increase
1105
(P ¼ 0:001) in the documentation of patient ID number, consultant name, diagnosis, anaesthesia, position of the patient, the use of tourniquet, the use of antibiotics, the use of drains, and record of intra-operative complications. The documentation of the details of name of patient, surgeon, anaesthetist, operation title, approach, findings, postoperative plan, and signature of surgeon also improved. The only criterion that was less well documented with the introduction of the proforma was the date of the operation, but this difference was not statistically significant. The overall compliance rate with the use of proforma was 90%. The results from the neighbouring unit were comparable to those achieved in our unit with the use of the proforma (Plates 3 and 4). Fifteen out of the 21 criteria assessed were documented in more than 80% of the operation notes reviewed from our unit, whilst 16 criteria out of 21 assessed in the neighbouring unit were documented in more than 80%.
Plates 3 and 4 The effect of proforma in our unit vs. a neighbouring unit where the proforma had been in use for 5 years.
1106
The only significant difference (P < 0:001) in documentation between the two units was the position of the patient, the use of tourniquet, and record of intra-operative complications.
H. Al Hussainy et al.
pertinent criteria. In addition, the results of the neighbouring hospital (5 years after the introduction of a proforma) compare favourably with ours (using the proforma) demonstrating that a high standard can be maintained even when the novelty has worn off.
Discussion There is no ideal method to improve the standard of operation note documentation. Hand written notes continue to be widely used but are the least comprehensive and legibility is usually a problem. Baigrie et al.1 demonstrated this in general surgery operation notes in 1994. In an audit of 264 operation notes in two district hospitals, they identified poor legibility in 70% of those written by consultants. Post-operative instructions were missing in twothirds of the notes. An alternate mode of documentation involves using computer-generated notes2,5—7 but this requires capital investment and training of staff, and the digital print out is not always easy to understand. O’Bichere and Sellu7 reported that computer generated operation notes scored higher in all criteria in contrast to template generated operation notes in general surgery, but stressed the need to train staff and have an efficient information and technology infrastructure. Dictated notes are another option but there is usually a time delay before the operation note appears in the patient’s hospital records. It is useful to write a brief interim note, but this means duplicating the work and the hand written note may not be legible. The proforma acts as aide-memoir. It is easy to use and does not require a lot of time to complete. In addition, it is cheap and does not require training before implementing. For patient management, audit and research proformas are easy to locate in the patients’ hospital records. The results from our unit reveal an improved standard of operation note documentation with the introduction of the proforma. The improvement in the documentation may be due to the fact that the proforma acts as an aide-memoir reminding the surgeon about various
Conclusion We have demonstrated the effectiveness of a proforma in significantly improving the standard of operation notes in orthopaedic and trauma surgery. We recommend the use of operation note proformas in orthopaedic and trauma surgery.
References 1. Baigrie RJ, Birch D, Dowling BL, Dehn TCB. An audit of the quality of operation notes in two district general hospitals; are we following Royal College guidelines? Ann R Coll Surg Eng 1994;76(Suppl):8—10. 2. Basad E. Importance of computer-based procedures. Planning & documentation in orthopaedic surgery. Orthopade 1999;28(3):277—84. 3. Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg (Edin) 1999;44(2):94—5. 4. Campling EA, Devlin HB, Hoile RW, Lunn JN. The report of the national enquiry into perioperative deaths 1990. 1992:131—4. 5. Dale RF, Midwinter MJ. Use of database management systems by surgeons to produce operation notes. Ann R Coll Surg Eng 1996;78(Suppl 6):272—5. 6. Deimel D, Messer E, Thielemann HG, Picha G. Standardized computer-based documentation system for diagnoses performance in orthopedics and traumatology. Dev Initial Appl Orthop 1999;28(3):285—91. 7. O’Bichere A, Sellu D. The quality of operation notes: can simple word processors help. Ann R Coll Surg Eng 1997; 79(Suppl):204—9. 8. Rigby K, Brown S, Lakin G, Balsitis M, Hosie KB. Use of a proforma improves colorectal cancer pathology reporting. Ann R Coll Surg Eng 1999;81(6):401—3. 9. The duties of a doctor registered with the General Medical Council. Good medical practice. The General Medical Council Guideline Booklet, 3rd Edition, May 2001. 10. The Royal College of Surgeons of England. Guidelines for clinicians on medical records and notes. 1994.
Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma H. Al Hussainya,c,*, F. Alib, S. Jonesb, J.C. McGregor-Rileyb, S. Sukumard a
Department of Orthopaedic & Trauma Surgery, University of Sheffield, Sheffield, England, UK Department of Orthopaedic and Trauma Surgery, Northern General Hospital, Sheffield, England, UK c Department of Orthopaedic & Trauma Surgery, Chesterfield and North Derbyshire Royal Hospital, Calow, Chesterfield, England, UK d Department of Orthopaedic and Trauma Surgery, Rotherham General Hospital, Rotherham, England, UK b
Accepted 1 October 2003
KEYWORDS Trauma surgery; Orthopaedic surgery; Operation note; Proforma
Summary Comprehensive documentation of surgical procedures is an essential component of good medical practice, but the standard of operation notes in orthopaedic and trauma surgery has been notoriously poor. The value of proformas in the production of high standard operation notes has been demonstrated in various surgical specialities. We have compared the standard of documentation of operation notes before and after the introduction of a proforma and report a significant improvement (P < 0:001) with the proforma. In addition, the results from a neighbouring hospital where a similar proforma was in use show a sustained standard of documentation 5 years after it was first used. ß 2003 Elsevier Ltd. All rights reserved.
Introduction An operation note is one of the means of communication between health care professionals and has a great impact on structuring a management plan post-operatively. It is the only legal record of the surgery performed, and like all legal documents it should be legible, dated, and contain pertinent information. The General Medical Council states that proper note keeping is an essential component of good medical practice.9 Despite this, the standard of operation notes in orthopaedic surgery is poor and the National Confidential Enquiry Into Peri*Corresponding author. Tel.: þ44-7931-811213. E-mail address: [email protected] (H. Al Hussainy).
Operative Death (NCEPOD) report of 1992—1993, described many orthopaedic notes as ‘‘. . . untidy one liners’’.4 Dictated notes, computer generated notes, and the use of a proforma are being used in an attempt to improve the standard of operation notes. The usefulness of a proforma in the disciplines of general surgery,8 and otorhinolaryngology3 has been shown in previous reports. This study examines the value of a proforma in improving the standard of operation notes in orthopaedic and trauma surgery.
Materials and methods Between January and July 1999, a review of the standard of operation notes in the Orthopaedic
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.016
Improving the standard of operation notes in orthopaedic and trauma surgery
Department of the Chesterfield and North Derbyshire Royal Hospital was undertaken. One thousand nine hundred and twenty-eight orthopaedic and trauma operation notes were identified from the operating theatre logbooks. The procedures of manipulation under anaesthetic, injection of steroid, and caudal epidural were excluded. Eightyeight case notes were randomly selected by computer and the operation notes were assessed by a single observer to determine if the notes met
Figure 1
1103
guidelines as stated by the Royal College of Surgeons10 (Table 1). Additional criteria relevant to orthopaedic and trauma surgery were also assessed (Table 2). An operation note proforma was devised (Fig. 1). It was used over a trial period of 2 weeks to determine its practicality, and then subsequently used routinely for all operations over a period of 8 weeks. Five hundred and ninety operation note proformas were used over the 8-week study period. Seventy-nine
The operation note proforma.
1104
H. Al Hussainy et al.
Table 1 shows the operation notes standard criteria as set by the Royal College of Surgeons of England
Table 2 shows the additional orthopaedic criteria used in the proforma
Royal College of Surgeons Guidelines Criteria
Additional orthopaedic criteria
Name of patient Identification number Consultant Operating surgeon Name of anaesthetist Method of anaesthesia Diagnosis Operation title Findings Procedure Prosthesis details Sutures used Intra-operative complications Post-operative instructions Signature
Date Position Approach Antibiotics given Use of tourniquet Drains Legibility
of these were then randomly selected for analysis. We then randomly selected 70 operation notes from a nearby District General Hospital in which a proforma had been in use for 5 years. A single observer reviewed these notes to determine if they met the Royal College guidelines (as above).
Plates 1 and 2 The inclusion percentages of the criteria (as set by the Royal College of Surgeons of England and the additional orthopaedic criteria) with and without the operation note proforma.
Improving the standard of operation notes in orthopaedic and trauma surgery
The results obtained before and after the proforma was introduced in our hospital were compared and analysed statistically using the Wilcoxon signed rank test. We compared our results (using the proforma) with the results from the neighbouring hospital.
Results Before the introduction of the proforma, the date, the operation title, procedure, method of closure of the surgical wound, the surgeon’s name, and signature were well documented. The details of patient ID number, pre-operative diagnosis, use of prophylactic antibiotics, position of the patient, and record of intra-operative complications were poorly documented (less than 35% of patients) (Plates 1 and 2). Following the introduction of the proforma in our unit, there was a statistically significant increase
1105
(P ¼ 0:001) in the documentation of patient ID number, consultant name, diagnosis, anaesthesia, position of the patient, the use of tourniquet, the use of antibiotics, the use of drains, and record of intra-operative complications. The documentation of the details of name of patient, surgeon, anaesthetist, operation title, approach, findings, postoperative plan, and signature of surgeon also improved. The only criterion that was less well documented with the introduction of the proforma was the date of the operation, but this difference was not statistically significant. The overall compliance rate with the use of proforma was 90%. The results from the neighbouring unit were comparable to those achieved in our unit with the use of the proforma (Plates 3 and 4). Fifteen out of the 21 criteria assessed were documented in more than 80% of the operation notes reviewed from our unit, whilst 16 criteria out of 21 assessed in the neighbouring unit were documented in more than 80%.
Plates 3 and 4 The effect of proforma in our unit vs. a neighbouring unit where the proforma had been in use for 5 years.
1106
The only significant difference (P < 0:001) in documentation between the two units was the position of the patient, the use of tourniquet, and record of intra-operative complications.
H. Al Hussainy et al.
pertinent criteria. In addition, the results of the neighbouring hospital (5 years after the introduction of a proforma) compare favourably with ours (using the proforma) demonstrating that a high standard can be maintained even when the novelty has worn off.
Discussion There is no ideal method to improve the standard of operation note documentation. Hand written notes continue to be widely used but are the least comprehensive and legibility is usually a problem. Baigrie et al.1 demonstrated this in general surgery operation notes in 1994. In an audit of 264 operation notes in two district hospitals, they identified poor legibility in 70% of those written by consultants. Post-operative instructions were missing in twothirds of the notes. An alternate mode of documentation involves using computer-generated notes2,5—7 but this requires capital investment and training of staff, and the digital print out is not always easy to understand. O’Bichere and Sellu7 reported that computer generated operation notes scored higher in all criteria in contrast to template generated operation notes in general surgery, but stressed the need to train staff and have an efficient information and technology infrastructure. Dictated notes are another option but there is usually a time delay before the operation note appears in the patient’s hospital records. It is useful to write a brief interim note, but this means duplicating the work and the hand written note may not be legible. The proforma acts as aide-memoir. It is easy to use and does not require a lot of time to complete. In addition, it is cheap and does not require training before implementing. For patient management, audit and research proformas are easy to locate in the patients’ hospital records. The results from our unit reveal an improved standard of operation note documentation with the introduction of the proforma. The improvement in the documentation may be due to the fact that the proforma acts as an aide-memoir reminding the surgeon about various
Conclusion We have demonstrated the effectiveness of a proforma in significantly improving the standard of operation notes in orthopaedic and trauma surgery. We recommend the use of operation note proformas in orthopaedic and trauma surgery.
References 1. Baigrie RJ, Birch D, Dowling BL, Dehn TCB. An audit of the quality of operation notes in two district general hospitals; are we following Royal College guidelines? Ann R Coll Surg Eng 1994;76(Suppl):8—10. 2. Basad E. Importance of computer-based procedures. Planning & documentation in orthopaedic surgery. Orthopade 1999;28(3):277—84. 3. Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg (Edin) 1999;44(2):94—5. 4. Campling EA, Devlin HB, Hoile RW, Lunn JN. The report of the national enquiry into perioperative deaths 1990. 1992:131—4. 5. Dale RF, Midwinter MJ. Use of database management systems by surgeons to produce operation notes. Ann R Coll Surg Eng 1996;78(Suppl 6):272—5. 6. Deimel D, Messer E, Thielemann HG, Picha G. Standardized computer-based documentation system for diagnoses performance in orthopedics and traumatology. Dev Initial Appl Orthop 1999;28(3):285—91. 7. O’Bichere A, Sellu D. The quality of operation notes: can simple word processors help. Ann R Coll Surg Eng 1997; 79(Suppl):204—9. 8. Rigby K, Brown S, Lakin G, Balsitis M, Hosie KB. Use of a proforma improves colorectal cancer pathology reporting. Ann R Coll Surg Eng 1999;81(6):401—3. 9. The duties of a doctor registered with the General Medical Council. Good medical practice. The General Medical Council Guideline Booklet, 3rd Edition, May 2001. 10. The Royal College of Surgeons of England. Guidelines for clinicians on medical records and notes. 1994.