Burns : journal of the International Society for Burn Injuries
-
An Operation Note should provide a comprehensive account of the details of a surgical procedure performed and document clinically relevant events which occur throughout the procedure. The Royal College of Surgeons of England, in 2014, updated guidelines on specific criteria to be included in operation notes. Standardisation using procedure-specific operation notes has been shown to significantly improve adherence to these guidelines. The aim of this study was to evaluate the quality of operation notes in the Irish National Burns Unit before and after the design and implementation of an electronic patient record and the subsequent introduction of an operation template and a burns surgery specific checklist, within the electronic system. ⋯ The use of an electronic patient record to document a patient's procedure has been shown to significantly improve the quality of documentation. One could expect this to result in an improved patient hand-over and subsequent episode of care. We highlight a number of initial pit-falls that others may avoid in their implementation of a digital record.