1. Computer Generated Operation Notes
Verity Currall and Tim Chesser
Frenchay Hospital, Bristol

2. Introduction
Providing an appropriate operation note is not only good practice1, it is a professional2 and legal requirement
Operation notes should be1:
Legible
Accompany the patient
Sufficiently detailed to enable continuity of care by another doctor
Providing an appropriate operation note is not only good practice1, it is a professional2 and legal requirement.
The operation note should be legible, accompany the patient and have sufficient detail to enable continuity of care by other healthcare staff1.

3. Introduction
Increasing importance due to changes in the working practices of junior staff:
ward- (rather than firm-) based teams
European Working Time Directive:
shorter shifts
more handovers
The last is particularly important, due changes in the working practices of junior staff, including ward- (rather than firm-) based teams and shorter shifts, with more handovers, because of the European Working Time Directive.

4. Introduction
Historically, operative notes have been handwritten, causing several problems:
use of abbreviations3
poor legibility4
lack of description of the procedure5
These problems are faced in all surgical specialties, but orthopaedic operation notes have come in for particular criticism
Historically, operative notes have been handwritten. This has given rise to several problems, including the use of abbreviations3, poor legibility4 and lack of description of the procedure5.
These problems are faced in all surgical specialties, but orthopaedic operation notes have come in for particular criticism, having been described as “untidy one-liners”6. Although this is probably a little harsh, this study investigates whether the use a computerised system can improve the quality of orthopaedic trauma operation notes.

5. Bluespier
Bluespier Patient Manager (Bluespier International, Grafton Flyford, Worcestershire, United Kingdom
Clinical information system
store outpatient and ward round notes as Word files
track inpatients
manage the trauma board and operating list.
The Bluespier Patient Manager was introduced into an orthopaedic trauma unit.
This clinical information system is used to store outpatient and ward round notes as Word files, track inpatients and manage the trauma board and operating list. A new patient episode is created when someone is seen for the first time with a new diagnosis by selecting the patient from a list created by an interface of Bluespier with the current Trust Patient Administration System (PAS) (online HL7).
An extra computer workstation with intranet access, plus a printer, were required in the trauma theatre to allow the generation and printing of operation notes by the surgeon. The operative notes, along with the other documents mentioned above, can, however, be accessed by approved healthcare workers (generally medical and nursing staff), via a password-protected system accessible from every computer in the hospital. In addition, Bluespier has research/audit functions, which allow the system to be interrogated to find, for example, the records of all patients undergoing a specified procedure in a particular timescale.

6. Bluespier Operation notes are generated via proformas drop down menus
click boxes
free text
Operation notes are also generated via proformas, which use a combination of drop down menus (Figure 1), click boxes (Figure 2) and free text.

9. Bluespier Operation notes are generated via proformas
drop down menus
click boxes
free text
Converted into final operation notes as Word files
These are converted into final operation notes as Word files (Figure 3).
These are then checked, saved and printed by the author, with a paper copy placed into the patient’s notes. It is also possible to type an operation note as free text in a Word document.

11. Bluespier Operation notes are generated via proformas
drop down menus
click boxes
free text
Converted into final operation notes as Word files
Checked, saved and printed, with a paper copy placed into the patient’s notes.
These are then checked, saved and printed by the author, with a paper copy placed into the patient’s notes. It is also possible to type an operation note as free text in a Word document.

12. Method
4 week prospective audit of all operation notes was conducted both before and after the introduction of Bluespier
Before
operation notes were handwritten on paper with only basic prompts
After
its use for operation notes was not compulsory, but was strongly encouraged.
A four week prospective audit of all operation notes was conducted both before and after the introduction of Bluespier.
Prior to its introduction, operation notes were handwritten on paper with only basic prompts (patient details, procedure and indication).
Bluespier’s use for operation notes was not compulsory, but was strongly encouraged.

13. Royal College Guidelines1
Patient name, hospital number, DOB
Date and time
Elective/emergency procedure
Operating surgeon and assistant
Consultant
Diagnosis
Procedure title
The audit standards were based on criteria set out by the Royal College of Surgeons of England1 ...

14. Royal College Guidelines1
Incision
Operative findings
Procedure details
Prostheses
Closure/sutures
Immediate post-operative instructions
Surgeon’s signature

15. Additional Orthopaedic Criteria6,7
Tourniquet time and pressure
Local anaesthetic
Antibiotic/DVT prophylaxis
Post op instructions:
Antibiotics
Check x-ray
Weightbearing/mobilisation
ROS
OPA
as well as additional orthopaedic criteria, based partly on British Orthopaedic Association guidelines7,8 …
Data were collected from the paper operative notes - whether written or computer-generated - in the patients’ medical records. Tick box proformas for the presence or absence of the criteria described above were filled in by the first author, bearing in mind that not all criteria would be applicable to every procedure (e.g. prostheses). The use of a tourniquet and/or local anaesthetic was cross-checked with the nursing record.

16. Results Before computer-generated notes:
After computer-generated notes:
137 notes
85% computer-generated, 15% written
One hundred and nineteen operation notes were reviewed before the introduction of computer-generated notes and 137 notes afterwards. Of these, 116 (85%) were generated via computer and 21 (15%) were handwritten.

17. Pre-Bluespier
In the notes from before the introduction of Bluespier, the criteria were generally met, but the documentation of tourniquet (pressure 17/33 = 52%; time 24/33 = 73%) and local anaesthetic (14/24 = 58%) use intraoperatively were poor. This was also the case for postoperative instructions, including check x-ray (67/85 = 79%), outpatient appointment (73/97 = 75%), suture removal (60/81 = 74%) and postoperative antibiotics (35/78 = 45%).

18. Pre- v Post-Bluespier
From a graphical comparison between the two sets of results (Figure 4), it can be seen that there were large differences in some of the criteria.
For these criteria, the post-Bluespier notes results were also divided into those operation notes generated using the computer and those which were still handwritten.

19. % Pre Computer Post Computer Total Written 84 96 100 76 83 95 88 81 97
DOB 84 96
100 76 WB 83 95 88
Consultant 81 97
Findings 80 98
X-ray 79 78 65
Position 77 90 92
OPA 75 87 91
Tourniquet time 73 89 93
Tourniquet pressure 52 86
Local 58 85
Antibiotics 45 55
Of the criteria where the post-computer notes scored more highly than the pre-computer notes, most (including general details, operative details and post-operative instructions) did so because the computer-generated notes were of a higher quality (ie had higher scores on the criteria). The post-Bluespier written notes had similar scores to the pre-Bluespier notes.
There were, however, a few exceptions (shown in red). The documentation of local anaesthetic and tourniquet use was much better in the post-Bluespier notes, but this improvement took place in both the computer-generated and written notes. There is no obvious explanation for this, although both criteria scored particularly badly before the introduction of computer-generated notes.

20. Results % Pre-Computer Post-Computer Total Computer Written 98 12 76
Signature 98 12 76
Designation 88 11 71
Author 20 5 33
Time 47 9 57
The only areas in which the computer-generated notes were worse than the handwritten notes were in the details of the author (name, designation and signature) and time of day, none of which are routinely contained in the computer-generated notes. With the exception of the signature, however, the other details are available from a separate audit trail function of the system.

21. Discussion
Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results
Several solutions to the problem have been tried:
aide-memoire in theatre3
proforma attached to notes8
operation notes produced by word processor using predesigned templates9
Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results4,5. Several solutions to the problem have previously been tried. The use of an aide-memoire in theatre has improved the quality of notes in ENT departments, in terms of patient details and abbreviations3, as well as adherence to Royal College guidelines9. The introduction of a proforma in trauma and orthopaedic surgery significantly improved the documentation of several criteria, including patient number, consultant, diagnosis, position and the use of tourniquets and antibiotics10.
With the advent of the National Programme for IT (NPfIT), computer generated notes are the next logical step. A computerised template with drop-down menus and free text proved better than handwritten notes in ENT emergency clinics11. An early database management system for general surgery was effective in collecting data and allowed the generation of operation notes, but their quality was not investigated12. In another study, operation notes produced by word processor using predesigned templates scored more highly than written notes using a proforma13.

22. Discussion
Quality of the operation notes improved after the introduction of a computer-generated operation note as part of the Bluespier clinical information system
Reasonable to attribute the change to the use of the Bluespier system
Lack of signature on the printed operation note:
education
electronic signatures
Our results show that the quality of the operation notes in most criteria improved after the introduction of a computer-generated operation note as part of the Bluespier clinical information system. Apart from the documentation of local anaesthetic and tourniquet use, the quality of written notes had not improved over the same period, so it is reasonable to attribute the change to the use of computer-generated operation notes. The main deficiency was the lack of signature on the final printed operation note, but should be easy to remedy with education or the use of electronic signatures.
Although ease and speed of use were not specifically investigated in this study, the general impression of the users was that the system is easy to use, although some of the proformas need minor alterations. It initially takes a few minutes more to produce a computer-generated note than a written one, but this decreases with familiarity and the use of personal default settings. There are also considerable time savings when needing to check an operation note if the paper notes are not readily available (for example, when a patient is readmitted or the notes have been lost before an outpatient appointment). In addition, audit and log book generation is easily achievable.

23. NHS Care Records Service10
Allow clinicians to access linked records from every NHS organisation used by a patient
Both primary and secondary care
Details of all investigations and treatment, including operation records
The NHS Care Records Service (CRS) will take several years to introduce, but will eventually allow clinicians to access linked records from every NHS organisation used by a patient (from both primary and secondary care), with details of all investigations and treatment, including operation records14. The Bluespier system achieves this in terms of operation notes, as well as ward round and outpatient notes.
Development will soon allow interface with PACS and laboratory investigations to allow a fully integrated system. Currently, 16 hospitals in the United Kingdom and Ireland (including ours) are using the Bluespier system15.

24. Summary
The introduction of computer-generated operation notes has improved their quality in terms of compliance with Royal College guidelines and other orthopaedic criteria
Compatible with the wider aims of NHS Care Records Service
In conclusion, the introduction of computer-generated operation notes has improved their quality in terms of compliance with both Royal College criteria and other orthopaedic criteria.
It is also compatible with the wider aims of the NHS Care Records Service

25. Thank You

26. References
The Royal College of Surgeons of England. Good Surgical Practice. London: The Royal College of Surgeons of England, 2002
General Medical Council. Good Medical Practice. London: General Medical Council, 2006
Bateman ND, Carney AS and Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg Edinb 1999; 44: 94-5
Mathew J, Baylis C, Saklani AP and Al-Dabbagh AR. Quality of operative notes in a district general hospital: a time for change? The Internet Journal of Surgery 2003; 5(1)

27. References
Baigrie RJ, Dowling BL, Birch D and Dehn TCB. An audit of the quality of operation notes in two district general hospitals: are we following Royal College guidelines? Ann R Coll Surg Eng (Suppl) 1994; 76: 8-10
British Orthopaedic Association. Knee Replacement - a Guide to Good Practice. London: British Orthopaedic Association, British Association for Surgery of the Knee, 1999
British Orthopaedic Association. Primary Total Hip Replacement: A Guide to Good Practice. London: British Orthopaedic Association, 2006
Al Hussainy H, Ali F, Jones S, McGregor-Riley JC and Sukumar S. Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma. Injury 2004; 35:

28. References
O’Bichere A and Sellu D. The quality of operation notes: can simple word processors help? Ann R Coll Surg Eng (Suppl) 1997; 79(5): 204-8
NHS Connecting for Health. Guidance for the NHS about Accessing Patient Information in New and Different Ways and What this Means for Patient Confidentiality. London: NHS Connecting for Health, 2006