Improving the quality and speed of access to operation notes

Introduction: Operation notes are often poorly completed, potentially compromising patient care. This project was undertaken to improve the quantity, quality and clarity of information included in operation notes, and make them easier to locate within a set of patient notes. Methods: Operation notes were audited against standards laid out in national guidelines. The time taken for staff to locate an operation note, and information within it, was then measured. The layout was re-designed, followed by a re-audit. Results: The number of operation notes with all measured domains completed rose from 4% to 34% (P<0.001). The mean time to locate the operation note fell from 30 to 4 seconds, and the mean time to locate all requested pieces of information within the operation note fell from 35 to 20 seconds. Conclusions: The interventions have improved quality and speed of access of operation notes, but there is still room for improvement.