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.