Title : Pansurgical electronic operative records within a national healthcare system: A single centre experience and national review of practice
Abstract:
Background: Clear, legible and accurate documentation remains an important medico-legal challenge, being fundamental to good medical practice as endorsed by the General Medical Council. Operative records are no exception with the Royal College of Surgeons of England (RCSEng) providing contemporaneous guidance on information they should include, preferably being typed.
Aims: Compare the clarity of electronic notes recorded on Bluespier with handwrittten operation notes to ascertain whether recording operations through Bluespier is as effective at complying with the RCSEng guidelines as handwriting, and describe the use of electronic operative records within a national healthcare system.
Methods: A single-centre, pansurgical, prospective review of 100 randomly selected operative records was carried out. Fisher’s exact test was used to compare compliance of handwritten versus electronic notes with the RCSEng guidelines. All NHS England trusts with surgical services were contacted with a questionnaire to collect data on use of electronic operative records.
Results: 78 records were handwritten of which illegibility necessitated a second independent review in 37.2%. None of the records met all guidelines with zero compliance noted in recording DVT prophylaxis, anticipated blood loss and elective/ emergency procedure. Only documentation of antibiotic prophylaxis was statistically higher in electronic versus handwritten records (46.4% vs 16.7%; p=0.03). 31 NHS England trusts responded of which 18 use electronic, six use handwritten and seven accept both handwritten and electronic records. 25 different electronic systems were identified with Cerner Milennium being used most often.
Conclusion: Compliance with the RCSEng guidelines remains poor warranting further education. Collaboration between software developers and surgeons may improve functionality and uptake of electronic systems. Practice across NHS England is variable with in-house and more widely available electronic systems in use questioning whether an era of homogenising programmes across trusts is the future.
