north western deanery junior doctors mr geoff chiu str: oral and maxillofacial surgery 11 th...
TRANSCRIPT
North Western Deanery
Junior Doctors
Mr Geoff Chiu StR: Oral and Maxillofacial Surgery
11th February 2014
SurgiNote
Operation Note
Hand over to post op team
Discharge summary
Follow up in Spoke Hospital
Clinical Governance
Clinical Coding
Unable to read notes or post op instructions
In-efficiency of Clinicians’ time
Duplication of information
Are notes available?
Finding accurate records
Code within target?
Accurate Coding?
Time consuming
Discharge Summary to GP < 24 hrs
Issues
Comments• “Much easier to read and locate”
• “Can understand post operative instructions”
• “Would be great if all specialties did the same”
• “Much better easier to read and well set out”
• “Find it very helpful to have op note typed, always concise and there are no
problems like trying to read handwriting”
• “Improves patient care as you can read all the info“
• “Excellent clear and concise”
• “Typed notes are much easier to identify in the medical notes”
SurgiNote:
Patient Care
Clinical Coding
Audit and Research
Commissioning
Education
Improved communication
Payment by results
Hospital Episode Statistics
Quality Assurance
Clinical Governance
Service Provision and planning
LogbookTraining Activity
Departmental Current level of activity
Surgeon Patient Related Outcome Measures
Shot himself, through chin
Squashed in a cheese press!
Fell of bike: handle bars
caught mouth
Neck Dissection
Harvesting fibula free flap
EarChin
Micro vascular Anastomosis
Somerset Cancer Register
Summary• The operation note is one of the most important pieces of information
that informs us about patient’s surgical care.
• SurgiNote has been developed and introduced to provide accurate high quality operation notes that can be used by all stakeholders.
• SurgiNote is innovative and creative.
• SurgiNote has been quantitatively and qualitatively assessed.
• SurgiNote has been proven to assist in improving high quality care for patients having surgery.