1009 Improving Accuracy and Extractability of Electronic Operative Documentation Data in a Hand Trauma Unit

Aim

Accurate and thorough operative documentation is essential for continuity of patient care, audit purposes, and the medicolegal protection of patients and doctors. In a hand trauma department in central London, challenges to this include a fast turnover of junior doctors, busy trauma lists, and complex, multidisciplinary cases.

‘Pathpoint’ is an online system with functionality for operative note templates and pre-filled data. However, it is unclear how much this is utilised in the department.

This project aimed to evaluate operative documentation for hand trauma and the utilisation of templates for data input.

Method

All hand trauma cases performed in a one-month period were requested from Pathpoint. Operation notes were initially screened for directly extractable data in template-form then manually checked for free-text data entry using prior-agreed criteria.

Results

The initial search yielded 51 procedures.

Nerve repairs were best documented (18% data missing), terminalisation procedures were worst documented (38% data missing). Overall, only 18.3% of all data were directly extractable; 0% data were extractable for dressings, post-operative antibiotics, follow-up and movement restrictions.

Best documented topics were hand trauma findings, skin closure, and follow-up. >90% of data in each of these were freetext.

Worst documented topics were CEPOD category, ASA grade, intra-operative antibiotics, and tourniquet details.

Conclusions

Despite overall good documentation, multiple important omissions are noted. Furthermore, the majority of data is not recorded in an extractable format. Templates have been distributed within the department. Re-auditing in subsequent months will assess whether accuracy of documentation and ease of data extraction have improved.