• Yaser Ghani, Raj Thakrar, Dennis Kosuge, and Peter Bates.
• Department of Trauma & Orthopaedic Surgery, Royal London Hospital, White Chapel Road, London E1 1BB, UK. Electronic address: y.ghani@doctors.org.uk.
• Int J Surg. 2014 Jan 1; 12 (5): 30-2.

AimsOperation notes are the only comprehensive account of what took place during surgery. Accurate and detailed documentation of surgical operation notes is crucial, both for post-operative management of patients and for medico-legal clarity. The aims of this study were to compare operation documentation against the Royal College of Surgeons of England guidelines and to compare the before-and-after effect of introducing an electronic operation note system.MethodsFifty consecutive operation notes for inpatients that had undergone emergency orthopaedic trauma surgery were audited. An electronic operation note proforma was then introduced and a re-audit carried out after its implementation.ResultsThe results after implementation of electronic operation notes, demonstrated a marked improvement. All notes contained an operation note (previously 5/6). Seventy five percent included time of surgery and age of patient (vs. 0% previously). A hundred percent included closure details and antibiotic selection at induction (vs. 60% and 69% respectively). Post-operative instructions improved to 100%. All were typed, making for 100% legibility as compared to only 66% of operation notes with legible hand writing in the initial audit.Discussion/ConclusionWe used our pilot audit to target specific information that was commonly omitted and we 'enforced' these areas using drop-down selections in electronic operation note. This study has demonstrated that implementation of an electronic operation note system markedly improved the quality of documentation, both in terms of information detail and readability. We would recommend this template system as a standard for operation note documentation.Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

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