A cross-sectional retrospective study comparing handwritten operation notes with electronic operation notes.

INTRODUCTION

Electronically completed medical notes have been shown to be superior in legibility and completeness to handwritten ones. Despite this, surgeons continue to use handwritten operation notes. This paper aims to compare the quality of handwritten versus electronic operation notes.

METHODS

This is a retrospective cross-sectional single-centre study done at Darent Valley Hospital, a district general hospital at Dartford, UK. We looked at 405 operation notes of patients who had general surgery procedures between 1 January 2020 to 31 January 2021 checking for legibility and completeness of operation note criteria as given by the Royal College of Surgeons of England's . Data were collated using an app that populates comparison criteria in an Excel sheet and were analysed using SPSS (Statistical Package for the Social Sciences). The results are presented in bar graphs and frequency table.

RESULTS

In 17 out of the 18 criteria in RCS England's , electronic notes were better completed than handwritten ones (<0.001). Signature as a criterion had comparable level of completeness in both handwritten and electronic notes, 95% versus 91% respectively. There was 8.3% illegibility in the handwritten note and none in the electronic ones.

CONCLUSIONS

Electronic notes are far better completed than handwritten notes in 17 out of the 18 criteria of a good operation note by RCS England. The difference between both forms of notes is far too much; we propose a complete shift in practice from handwritten to electronic format.