DOCUMENTATION OF SURGICAL PROCEDURE : WHY & HOW Hieder A’ala
May 14, 2015
DOCUMENTATION OF SURGICAL PROCEDURE : WHY & HOWHieder A’ala
WHY Documentation and archieving
Reviewing the effectivness of training
Recording the wired cases
Matter of education through case-based approach
HOW ….CRITERIA OF GOOD DOCUMENTATION
Objective data…not subjective Honesty in writing. Continuity Postoperative follow up Good classification of the surgery undertaken Ability to find the procedure without delay Commentary ( on the procedure which was
read prior to procedure ) other than descriptive.
METHODS
1.Program-based
2.Written work
3.Web-based
4.Media
1. PROGRAM BASED
The European Neurosurgical Electronic Logbook of Operations
1. PROGRAM BASED…CONT.
Electronic version of this logbook that helps the trainee to record all operations in an easy and fast way.
Runs under any version of Microsoft Windows
The EANS published a detailed list of operations with minimum and optimum figures for each entry that a trainee must meet at the end of his training
It is not depended on any external programs
CONTINUE
The application is designed to support multiple languages for all text messages and the list of diagnoses
For security reasons all data entered is encrypted
To allow multiple users to access their data on one single computer, the application supports an unlimited number of accounts that can be accessed by one installation of the program
Installation of the application is as straightforward as installing other standard applications
Both lists mentioned can be printed
ROLE OF THE TRAINEE DURING THE OPERATION
This value can either be “T” , “TS”, “C” or “A”: T=Trainee: The trainee has done the
operation. The supervising consultant must not have made a decision/practical manoeuvre significantly affecting the execution of the operation.
TS=Trainee (+Consultant Supervising): The trainee has done the operation but the supervising consultant has made a significant decision/practical manoeuvre during the operation.
C=Component: The trainee has performed component parts during the operation under supervision of a senior surgeon: Positioning, operative approach, closure, drainage, draping, instructions for postoperative care.
A=Assistant: The trainee is the principal assistant during the operation.
2.FORMAL WRITTEN
The eldest way to record
Depends on ability of recorder to fullfil all fields
Obligate us to read prior to write
Nothing not important, keep your mind with the seniors and register every data
2.FORMAL WRITTEN
Not comfortable
All data around us recorded by new technologies
Return to previous cases is not so easy
2.FORMAL WRITTEN
written\My Real Logbook\Trauma Cranial sheet.doc
2.FORMAL WRITTEN ..CONT.
3.WEB-BASED
Few sites were constructed for such mission The data is stored in place other than my
computer
Revision and recording need internet access
The available site is not free
Well organized data and fields, no place for blurred subjects and specific.
CONTINUE The web facilitate revision with trainer
Accredited from well known organisation.
4.MEDIA
Advantages :
Audio recording represents one of the old method to record
Video and photos capturing are new quit methods to save pt. pictures and operative steps
4.MEDIA
Disadvantages :
Continuity not always possible
Needs tool ( high cam zooming )
Needs someone to capture them
Microscopic recording is the best
4.MEDIA
Example : method 1 folder of pics and sound file
4.MEDIA
Example :
4.MEDIA
Example :
4.MEDIA
Example : method 2 microscope recording
THE FINAL WORD
Be honest with your data