Improving the quality of operation notes with electronic proformas

Abstract

Introduction

Surgeons must ensure operative notes are legible and sufficiently detailed, outlined by 21 criteria in Good Surgical Practice guidelines (2014). Our aim was to introduce an electronic operating proforma to improve quality of operation notes.

Methods

Two audits were performed six months apart, after an education session and introduction of an electronic operating proforma, assessing adherence to the guidelines. Results were compared and analysed using Chi-square and Fisher’s exact tests.

Results

In both audits, notes for 187 operations performed over a two-week period were studied. In the first audit, six of the 21 criteria were recorded in ≥95% of operation notes, improving to nine in the second audit. In the second audit cycle, two subgroups were analysed, non-proforma (n = 30) and proforma (n = 157). In the proforma subgroup, 15 criteria were recorded in ≥95% of operation notes.

Conclusion

Quality of operation notes can be significantly improved by using a combination of education, electronic proformas and avoiding handwritten notes.