A quality improvement project: novel electronic operative note templates to improve the continuity of post-operative patient care

ABSTRACT

Introduction: Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid- 19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients' erecords which adhere to RCSEng guidelines. Method: In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle. Results: 261 patients were included in both study periods. Only 36/ 134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%). Conclusions: Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of etemplate was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.