The quality of operation notes: can simple word processors help? 1997

A O'Bichere, and D Sellu
Department of Surgery, Ealing Hospital NHS Trust, Southall, Middlesex.

In a retrospective study the quality of operation notes on specifically designed proformas was compared to those produced by word processors and predesigned templates and notes in patients undergoing operations for colorectal cancer. The operations in the two groups were similar. Computer notes scored higher on all criteria, were all legible and took the same time to generate. The results were given to staff in an attempt to improve the quality of future notes. Prospective comparison demonstrated that the quality of computer notes improved even further, while that of manual forms did not change. Word processor computer notes are easy to set up, amend and produce but staff should be trained in the use of personal computers and machines must be readily available in operating theatres. Word processor databases will, in addition, enable the data collected to be analysed automatically to yield information for audit and research.

UI MeSH Term Description Entries
D008485 Medical Audit A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of medical care. Audit, Medical,Audits, Medical,Medical Audits
D008499 Medical Records Recording of pertinent information concerning patient's illness or illnesses. Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D011446 Prospective Studies Observation of a population for a sufficient number of persons over a sufficient number of years to generate incidence or mortality rates subsequent to the selection of the study group. Prospective Study,Studies, Prospective,Study, Prospective
D011786 Quality Control A system for verifying and maintaining a desired level of quality in a product or process by careful planning, use of proper equipment, continued inspection, and corrective action as required. (Random House Unabridged Dictionary, 2d ed) Control, Quality,Controls, Quality,Quality Controls
D004739 England A part of Great Britain within the United Kingdom.
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D012189 Retrospective Studies Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons. Retrospective Study,Studies, Retrospective,Study, Retrospective
D013503 Surgery Department, Hospital Hospital department which administers all departmental functions and the provision of surgical diagnostic and therapeutic services. Hospital Surgery Department,Department, Hospital Surgery,Surgery Departments, Hospital,Surgical Service, Hospital,Departments, Hospital Surgery,Hospital Surgery Departments
D015179 Colorectal Neoplasms Tumors or cancer of the COLON or the RECTUM or both. Risk factors for colorectal cancer include chronic ULCERATIVE COLITIS; FAMILIAL POLYPOSIS COLI; exposure to ASBESTOS; and irradiation of the CERVIX UTERI. Colorectal Cancer,Colorectal Carcinoma,Colorectal Tumors,Neoplasms, Colorectal,Cancer, Colorectal,Cancers, Colorectal,Carcinoma, Colorectal,Carcinomas, Colorectal,Colorectal Cancers,Colorectal Carcinomas,Colorectal Neoplasm,Colorectal Tumor,Neoplasm, Colorectal,Tumor, Colorectal,Tumors, Colorectal
D015443 Word Processing Text editing and storage functions using computer software. Processing, Word,Processings, Word,Word Processings

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