A Comparison of Handwritten to Computerised Urological Operative Notes

Abstract

Introduction:

Operative notes are traditionally handwritten and are essential for providing optimal postoperative care and planning the future management of patients. This study compares handwritten to computerised operative notes using a common standard.

Method:

One hundred handwritten urological operative notes were compared to 97 urological database printed notes using the Royal College of Surgeons' of England (RCSEng) guidelines for Good Surgical Practice.

Results:

There was an overall improvement in the quality of documentation, excluding the recording of tissue removed and the presence of a signature. The recording of parameters in the printed operative database notes was greater than 95% in 16 out of 18 parameters assessed.

Conclusion:

We strongly recommend the use of an operative database to raise the standard of operative notes in order to improve patient care and to provide a robust medico-legal record.