Title : Audit of Handwritten vs Electronic Surgical Operation Notes at King George Hospital: Based on Royal College of Surgeons of England Guidance as gold standard
Compare the clarity of electronic notes recorded on Bluespier with handwrittten operation notes and ascertain whether recording operations through Bluespier is as effective at complying with the RCSEng guidelines as handwriting
A prospective review of 100 operation notes across all surgical specialties at King George Hospital against the RCSEng guidelines. Where data collection was limited due to illegibility, a second auditor reviewed the note. Fishers exact test was carried out to compare compliance of handwritten vs electronic notes with the RCSEng guidelines
Out of 78 handwritten notes, 37.2% required a second independent review. Not a single operation note met all of the RCSEng guidelines. Although a number of operation note components show good/fair compliance, a zero compliance was noted in recording DVT prophylaxis, anticipated blood loss and type of surgery. Electronic notes are statistically better than handwritten notes at recording antibiotic prophylaxis only (p<0.05).
Bluespier is a good platform for creation of clear operation notes and its use should be encouraged. We recommend making Bluespier more user friendly through developing standardized operating notes templates with mandatory fields and creating templates of professional anatomical images. We also recommend educating surgical trainees on the RCSEng guidance and displaying guidelines in theatres