C James, A Cook, R Ray, R Goddard, G Slater
accuracy, operation notes, surgery
C James, A Cook, R Ray, R Goddard, G Slater. Producing Operative Notes using Microsoft Word with Forms Fields. The Internet Journal of Orthopedic Surgery. 2006 Volume 5 Number 1.
It is vital in this evolving medico-litigious era that medical notes are accurate, reproducible and legible. We describe our method of producing operative notes that fulfil these criteria and are simple to create using Microsoft Word with the aid of Form Fields.
This effective method is available to all orthopaedic surgeons and does not entail the cost that comes with other operative note programs
We describe the use of Form fields with Microsoft Word as a simple, effective way to produce typed operation notes.
‘Form' fields in Microsoft Word is available with all computers using Microsoft Windows software. Forms may be inserted into the Words template and then protected, with users only able to insert information using form fields. The template cannot be altered in any other way. As a result the completed forms are consistent in appearance and content.
Forms offers three types of information input: 1) text , 2) check boxes , 3) drop down lists, and these allow direct formatting of the word template to fit the operation. Text fields provide a place to type information; check box fields give you a choice of items to select or deselect; and dropdown list fields let you choose an entry from a list.
We use forms for all of our orthopaedic operations including elective and trauma. Whilst many operations are standardised in their manner, this simple method allows surgeons to carry the Forms programmes on a memory stick or laptop and input into theatre computers that will print off operative notes directly.
Accurate operative notes are part of good medical practice as outlined by the General Medical Council who state that all U.K doctors should “ keep clear, accurate and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to the patients and any drugs or other treatments prescribed”.(1)
The RCS England has also advocated the requirement for high quality operation notes (2) and thus it is now essential, especially in the present medico-litigious climate that accurate and suitable notes for each operation are compiled. (3)
There are currently different methods of producing operation notes, with the commonest being handwritten. These may be variable for a single operation and are often not completed by the primary surgeon. They also depend upon handwriting that is fully legible (4, 5). Dictated notes are similar in their variability and are also dependant upon the typist.
Proforma sheets and aide memoirs have been shown to improve the accuracy of the notes (5,6) but the most accurate method has been shown to be with Word programmes and databases such as the BOIS (Belfast Orthopaedic Operating System (7,8).
The form field is accessed in Word via:
We have used an example from an arthroscopy form Figure 1. This is a good representation as it is usually a standardised procedure but can have very variable findings that need changing on the form. The drop down and text boxes allow the details of the patient and of the operation to be accurately inserted into word form.
Windows Word with Forms Fields is a simple and effective way to produce operative notes. Word is accessible to most surgeons, and computers in the UK should be present in all operating theatres. Previous studies have shown that operation details are more accurate if compiled from computer than if by hand. There are other databases that can produce similar forms, but these involve the cost of buying the software, whilst our method is very cost effective being free with Windows Word. It is also a very simple program to use with internet instructions available on the Windows website. As with all operative notes, the form should be completed after each operation rather than at the end of the list and can then be printed to any desired quantity. It is also possible to protect the program with password aiding patient information security.
Whilst we use this for orthopaedic operations it is certainly a simple method available to all surgeons and we advocate the use for operative notes within all surgical specialities.