For the 11.5 million patients undergoing a surgical procedure in the NHS each year, the operation note is the medico-legal documentation of their surgery. Written by the surgeon immediately after the operation, it contains full details of the procedure including:
- The name and description of the procedure performed.
- Clinicians responsible.
- What was found/seen during the operation.
- Key decisions based on the findings.
- The ongoing treatment plan.
Surgeons often supplement text with diagrams, to better describe findings or their procedure.
Operation notes are the main way in which the surgical team communicates with other healthcare professionals like nurses, physiotherapists and ward doctors. Additionally, the information contained in the operation notes generally forms the basis of the discharge summary, which is how the GP is updated. Given this, it’s of paramount importance that operation notes are both accurate and legible so that high quality care can be delivered.
Current practice in NHS hospitals is that around 40% of operation notes are handwritten and another 40% use basic word processing. Multiple scientific studies have shown that the quality of operation notes is improved by using templates or proformas which reduce omissions and save surgeons time. Typed notes reduces illegibility. These are particularly important from a litigation point of view, as surgery is an area of medicine which has a relatively higher rate of mal-practice claims. Currently 2% of the NHS budget is spent on litigation so this is an important issue for surgeons, hospitals and the tax payer.
MyOpNotes - digital operation notes is a software solution that allows surgeons to rapidly write a high-quality operation note, automatically captures all data for research & audit, and enable hospitals to get better reimbursed. To find out more, get in touch today.