Transcript SurgiNote Presentation

11th February 2014
North Western Deanery
Junior Doctors
Mr Geoff Chiu
StR: Oral and Maxillofacial
Surgery
SurgiNote
Issues
Hand over to post op team
Discharge summary
Unable to read notes or
post op instructions
In-efficiency of Clinicians’ time
Duplication of information
Discharge Summary to GP < 24 hrs
Operation Note
Follow up in Spoke Hospital
Are notes available?
Clinical Governance
Finding accurate records
Time consuming
Clinical Coding
Accurate Coding?
Code within target?
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”
Patient Care
Clinical Coding
Improved communication
Payment by results
Hospital Episode Statistics
SurgiNote:
Surgeon
Patient Related Outcome Measures
Audit and Research
Quality Assurance
Clinical Governance
Commissioning
Service Provision and planning
Departmental
Current level of activity
Education
Training Activity
Logbook
Shot himself,
through chin
Fell of bike:
handle bars
caught mouth
Squashed in a
cheese press!
Pre
Prosthetic
Surgery
Infection 2%
Soft
Salivary
Tissue Orthognathic
1%
1%
Lesions
2%
Other
1%
3%
Oncology
5%
Skin Lesions
6%
Trauma
8%
Dentoalveolar
59%
Biopsies
12%
Micro vascular Anastomosis
Ear
Chin
Neck
Dissection
Harvesting fibula free flap
Somerset Cancer Register
SCR
Pre operative
SurgiNote
Inpatient
SCR
Postoperative
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.