Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

Abstract

The RCS has published clear and succinct guidelines dictating the necessity for the documentation of legible and timely surgical operative notes and exactly what should be included.A baseline study within the upper limb unit at our trust showed a 71.1% adherence with the RCS guidelines with an average delay of typing of notes after dictation was 11.6 days. This quality improvement project designed and developed a bespoke electronic surgical notes template built within an existing database driven software within the Trust. After implementation of the templates we found no delays in full operative notes being typed and a 100% adherence with the RCS guidelines. This project significantly improved the quality and timely production of electronic surgical notes within a sustainable electronic software solution.