Otamas A1#, Bedwani NH1#, Ogedegbe AJ1, Patten DK2,3*
1Department of General and Emergency Surgery, King George Hospital, Barking, Havering and Redbridge University Hospital NHS trust, Romford, London, UK
2 Department of General and Emergency Surgery, Whipps Cross University Hospital, Whipps Cross Road, London, UK
3 Department of Surgery and Cancer, The Imperial Centre for Translational and Experimental Medicine, Imperial College London, Hammersmith Campus, London, UK
*Corresponding author: Darren K. Patten, Department of General and Emergency Surgery, Whipps Cross University Hospital, Whipps Cross Road, London, UK, Tel: (+44)-772-301-8464; E-mail: [email protected]; #Equal contribution.
Received: September 28, 2020
Published: November 23, 2020
Background: Clear, legible and accurate documentation remains an important medico-legal challenge, being fundamental to good medical practice as endorsed by the General Medical Council. Operative records are no exception with the Royal College of Surgeons of England (RCSEng) providing contemporaneous guidance on information they should include, preferably being typed.
Method: A single-centre, pansurgical, prospective review of 100 randomly selected operative records was carried out. Fisher’s exact test was used to compare compliance of handwritten versus electronic notes with the RCSEng guidelines. All NHS England trusts with surgical services were contacted with a questionnaire to collect data on use of electronic operative records.
Results: 78 records were handwritten of which illegibility necessitated a second independent review in 37.2%. None of the records met all guidelines with zero compliance noted in recording DVT prophylaxis, anticipated blood loss and elective/emergency procedure. Only documentation of antibiotic prophylaxis was statistically higher in electronic versus handwritten records (46.4% vs 16.7%; p = 0.03). 31 NHS England trusts responded of which 18 useelectronic, six usehandwritten and seven accept both handwritten and electronic records. 25 different electronic systems were identified with Cerner Milennium being used most often.
Conclusion: Compliance withthe RCSEng guidelines remains poor warranting further education. Collaboration between software developers and surgeons may improve functionality and uptakeof electronic systems. Practice across NHS England is variable with in-house and more widely available electronic systems in use questioning whether an era of homogenising programmes across trusts is the future.
KEYWORDS: Operative records; Electronic systems; Handwritten; Rcseng guidelines; Compliance