Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation

[摘要] An operation note is a medicolegal document. The RoyalCollege of Surgeons (RCS) of England’s Good SurgicalPractice 2014 (GSP) sets out 19 points an operationnote should include. This study aimed to assess ifthe introduction of an electronic patient record (EPR)improved the quality of general surgical operation notes.An annonymised retrospective case note review ofgeneral surgical operation notes was undertaken over fiveseparate time periods. The first cycle consisted of periods1 (prior to EPR implementation), 2 (1 week after EPR) and 3(4 weeks after EPR). Period 4 was a reaudit 2 weeks afterthe initial results were presented at the local governancemeeting. The cycle was then closed with period 5; 1 yearafter EPR implementation. A comparison was across all5 time periods for compliance with the RCS guidelinesand with subanalysis of the individual categories. 250operation notes were reviewed during five time periods.Compliance improved by almost 19% (p=0.0003) betweenperiods 1 and 5. Eleven of the 19 points (57.9%) overthe audit period achieved 100% compliance post-EPRcompared to 0% prior. Poor compliance were noted in thecategories of antibiotic use, venous thromboembolismprophylaxis and estimated blood loss (noting that these areoften documented in the anaesthetic record and/or WHOchecklist). EPRs do not guarantee compliance with GSP. Wepropose that GSP standards need to be updated to reflectthe modernisation of medical records and a team-basedapproach with multimodality input sources would achievebetter patient records and patient care.

[学科分类] 药学