MyOpNotes is a revolutionary system built by surgeons for surgeons to solve the issues relating to the inefficient recording of operation notes. There are substantial benefits of MyOpNotes to surgeons, Trusts and patients. This article will explore the nature of an operation note, the problem currently faced, and how MyOpNotes provides value to all stakeholders for hospitals, surgeons and patients.

An operation note is a vital medico-legal document written by the surgeon straight after finishing the surgery. It records exactly what procedure was performed, who was involved, and the next steps in the patient’s treatment plan. It is the single most important piece of documentation for a surgical patient.

Current practice for operation notes in the NHS is in the dark ages. Out of nearly 8 million op notes written annually across NHS hospitals, up to 3.6 million are still handwritten with around 3700 per day being illegibile.

Research shows that surgeons generally write poor quality op notes when not using pro-formas or templates, whereby missing data is very commonplace including even the patient’s name or date of birth. Additionally, paper op notes also get lost. Thus, the issue of handwritten op notes is a serious patient safety, governance and medico-legal concern, which can cost stakeholders dearly in litigation. For Trusts, handwritten op notes cause procedures to be incorrectly coded and this results in loss of revenues, costing hospitals money. One systematic review showed that up to 20% of surgical procedures are incorrectly coded.

For surgeons, our intuitive dynamic templates make it easy to write a high-quality digital op note in less than 3 minutes. Smart analysis and integration with NHS Spine will allow for the auto-fill of patient and clinician details, automatic suggestions of common answers, and the detection of missing fields, greatly reducing repetitive work and chance of error. Attachments such as photos and videos, as well as the ability to annotate a standardised set of diagrams will make digital op notes more detailed than ever before. This protects surgeons and NHS trusts from litigation and improves patient care through clear communication with nurses and physios. Finally, surgeons can use advanced custom reporting to instantly pull up all operations that match a custom criteria based on the information within the note making tasks like completing your clinical audits a breeze.

For Trusts, the digitalisation, standardisation, and automation of operation notes reduces the chance of litigation and malpractice claims. Automatic OPCS coding may increase revenues, and one-click audits with live operation stats completely replace the current time-consuming manual process. Finally, MyOpNotes is intuitive, interoperable, non-intrusive, and has training built-in meaning it can be dropped into any hospital with ease, integrating with existing systems, and providing real value, saving Trusts money in the process.

For patients, MyOpNotes opens up an entire new field of potential research with previously unobtainable big data sets leading to improvements in patient care, better research in surgical techniques, and as a result, increased quality of healthcare across the UK.

Get in touch today and find out how easy it is to deploy MyOpNotes into your hospital.

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