Abstract
Introduction: Increasing medicolegal pressures, as well as problems with continuity of care and trauma patients outlying on non-orthopaedic wards, led to a concern regarding the quality of operation notes, especially with regard to postoperative instructions. A computerised system was introduced to address these issues.
Method: The quality of trauma operation notes was surveyed over a period of four weeks, before and after the introduction of the computerised system. Royal College of Surgeons guidelines, as well as additional orthopaedic criteria, were used as the expected standards.
Results: Most criteria were met significantly more of the time after the introduction of the computer generated notes, including antibiotic prophylaxis, weightbearing status and outpatient appointment.
Discussion: A computerised system is an effective and acceptable way of improving the standard of trauma operating notes. Users should be reminded to sign the resulting printed note until a full paperless record is in place.
Correspondence should be addressed to David Bracey, Honorary Secretary c/o Royal Cornwall Hospitals Trust, Truro, Cornwall TR1 3LJ
