A comparison of handwritten to computerised urological operative notes

Summary 

Introduction

Operative notes are traditionally handwritten and are essential for providing optimal postoperative care and planning the future management of patients. This study compares handwritten to computerised operative notes using a common standard.

Method

One hundred handwritten urological operative notes were compared to 97 urological database printed notes using the Royal College of Surgeons’ of England (RCSEng) guidelines for Good Surgical Practice.

Results

There was an overall improvement in the quality of documentation, excluding the recording of tissue removed and the presence of a signature. The recording of parameters in the printed operative database notes was greater than 95% in 16 out of 18 parameters assessed.

Conclusion

We strongly recommend the use of an operative database to raise the standard of operative notes in order to improve patient care and to provide a robust medico-legal record.

Keywords: Medical audit, Information systems, Medical records, Medical record systems, Computerised database management systems, Surgery