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Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation

An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of England’s Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should include. This study aimed to assess if the introduction of an electronic patient record (EPR) improved the quality of general su...

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Autores principales: Aldoori, Joanna, Drye, Naomi, Peter, Mark, Barrie, Jenifer
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937033/
https://www.ncbi.nlm.nih.gov/pubmed/31909211
http://dx.doi.org/10.1136/bmjoq-2019-000766
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author Aldoori, Joanna
Drye, Naomi
Peter, Mark
Barrie, Jenifer
author_facet Aldoori, Joanna
Drye, Naomi
Peter, Mark
Barrie, Jenifer
author_sort Aldoori, Joanna
collection PubMed
description An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of England’s Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should include. This study aimed to assess if the introduction of an electronic patient record (EPR) improved the quality of general surgical operation notes. An annonymised retrospective case note review of general surgical operation notes was undertaken over five separate time periods. The first cycle consisted of periods 1 (prior to EPR implementation), 2 (1 week after EPR) and 3 (4 weeks after EPR). Period 4 was a reaudit 2 weeks after the initial results were presented at the local governance meeting. The cycle was then closed with period 5; 1 year after EPR implementation. A comparison was across all 5 time periods for compliance with the RCS guidelines and with subanalysis of the individual categories. 250 operation notes were reviewed during five time periods. Compliance improved by almost 19% (p=0.0003) between periods 1 and 5. Eleven of the 19 points (57.9%) over the audit period achieved 100% compliance post-EPR compared to 0% prior. Poor compliance were noted in the categories of antibiotic use, venous thromboembolism prophylaxis and estimated blood loss (noting that these are often documented in the anaesthetic record and/or WHO checklist). EPRs do not guarantee compliance with GSP. We propose that GSP standards need to be updated to reflect the modernisation of medical records and a team-based approach with multimodality input sources would achieve better patient records and patient care.
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spelling pubmed-69370332020-01-06 Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation Aldoori, Joanna Drye, Naomi Peter, Mark Barrie, Jenifer BMJ Open Qual Quality Improvement Report An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of England’s Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should include. This study aimed to assess if the introduction of an electronic patient record (EPR) improved the quality of general surgical operation notes. An annonymised retrospective case note review of general surgical operation notes was undertaken over five separate time periods. The first cycle consisted of periods 1 (prior to EPR implementation), 2 (1 week after EPR) and 3 (4 weeks after EPR). Period 4 was a reaudit 2 weeks after the initial results were presented at the local governance meeting. The cycle was then closed with period 5; 1 year after EPR implementation. A comparison was across all 5 time periods for compliance with the RCS guidelines and with subanalysis of the individual categories. 250 operation notes were reviewed during five time periods. Compliance improved by almost 19% (p=0.0003) between periods 1 and 5. Eleven of the 19 points (57.9%) over the audit period achieved 100% compliance post-EPR compared to 0% prior. Poor compliance were noted in the categories of antibiotic use, venous thromboembolism prophylaxis and estimated blood loss (noting that these are often documented in the anaesthetic record and/or WHO checklist). EPRs do not guarantee compliance with GSP. We propose that GSP standards need to be updated to reflect the modernisation of medical records and a team-based approach with multimodality input sources would achieve better patient records and patient care. BMJ Publishing Group 2019-12-02 /pmc/articles/PMC6937033/ /pubmed/31909211 http://dx.doi.org/10.1136/bmjoq-2019-000766 Text en © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
spellingShingle Quality Improvement Report
Aldoori, Joanna
Drye, Naomi
Peter, Mark
Barrie, Jenifer
Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
title Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
title_full Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
title_fullStr Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
title_full_unstemmed Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
title_short Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
title_sort introduction of an electronic patient record (epr) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation
topic Quality Improvement Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937033/
https://www.ncbi.nlm.nih.gov/pubmed/31909211
http://dx.doi.org/10.1136/bmjoq-2019-000766
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