Improving the documentation of flexible cystoscopy notes: Case for introduction of electronic patient records?

Abstract

Introduction/Objective: Good surgical practice dictates that comprehensive and legible records are maintained by surgeons of all their interactions with patients. Flexible cystoscopy (FC) notes should be no exception to this standard. Currently at our institution, for every cystoscopy, FC operators document the same information in two different locations: handwritten in patient notes and electronic discharge letter. Methods: A closed-loop audit of FC notes at our institution was undertaken and data were collected prospectively using patients’ notes. Notes were scrutinised against the Royal College of Surgeons (RCS)/British Association of Urological Surgeons (BAUS) standards. The first period was 13–17 October 2015, and the second period was 20–31 May 2016. A total of 73 patients were included (43+30). Results: The first cycle highlighted several areas requiring improvement. Eight of 15 parameters fell short of the 100% target compliance: time (5.9%), responsible consultant (32.4%), operator (50%), postoperative instructions (82.4%), indication for FC (85.3%), date (88.2%), procedure name (91.2%) and signature (97%). Subsequently, a new electronic FC proforma was designed using the RCS/BAUS criteria for data to be documented. A successive re-audit using identical criteria established 100% compliance in all fields. Conclusion: Adopting the new proforma significantly improved the quality of FC documentation. Subsequently, new online software incorporating our proforma was introduced as part of electronic patient records, allowing for data to be easily accessed and read. We discuss the relevance of this in the context of existing literature. Level of evidence: Not applicable for this multicentre audit.