Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

Kanthan Theivendran; Sami Hassan; David I Clark

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Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

机译：通过在皇家德比医院实施上肢手术的新电子模板来提高手术笔记的质量。

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Abstract The RCS has published clear and succinct guidelines dictating the necessity for the documentation of legible and timely surgical operative notes and exactly what should be included.A baseline study within the upper limb unit at our trust showed a 71.1% adherence with the RCS guidelines with an average delay of typing of notes after dictation was 11.6 days. This quality improvement project designed and developed a bespoke electronic surgical notes template built within an existing database driven software within the Trust. After implementation of the templates we found no delays in full operative notes being typed and a 100% adherence with the RCS guidelines. This project significantly improved the quality and timely production of electronic surgical notes within a sustainable electronic software solution.

机译：摘要RCS已发布清晰简洁的指南，表明必须记录清晰，及时的手术操作说明以及应确切记录的内容。在我们信任的上肢单位内进行的基线研究表明，RCS指南遵守率达71.1％。听写之后，录入笔记的平均延迟为11.6天。此质量改进项目设计和开发了定制的电子手术笔记模板，该模板建立在Trust内部现有数据库驱动的软件中。实施模板后，我们发现输入完整的操作说明没有任何延迟，并且100％遵守了RCS指南。该项目在可持续的电子软件解决方案中大大提高了电子手术记录的质量和及时生产。

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《BMJ Open Quality》 |2016年第1期|共页
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Kanthan Theivendran; Sami Hassan; David I Clark;
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中图分类医药、卫生;
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6. Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital. [O] . Kanthan Theivendran, Sami Hassan, David I Clark 2016

机译：通过在皇家德比医院实施上肢手术的新电子模板来提高手术笔记的质量。
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Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

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