Endocrinology & Metabolic Syndrome
Open Access

Improving Operative Notes Documentation by introducing IT electronic changes to e-documentation

19th World Congress on Endocrinology & Diabetes

November 22-23, 2023 | Webinar

Mina Aziz

Aneurin Bevan University Health Board, United Kingdom

Scientific Tracks Abstracts: Endocrinol Metab Syndr

Abstract :

Introduction: Informed consent is an important aspect in patient’s care. Failings in this area may result in Medical records are important for adequate continuity of care patient’s management. Good medical records are essential for health professionals to use when defending against complaints or claims of clinical negligence because they give insight into the clinical judgement that was being used at the time. Records that are sufficient for continuity of care are typically also sufficiently thorough for legal purpose. Patients and Methods: Operative entries of all General Surgery patients were reviewed retrospectively on ORMIS; data were recorded on a sample of 20 patients. Data were recorded and analysed on a Microsoft Excel spreadsheet, and the information was recorded as present or absent. Results: Poor Documentation: Elective / Emergency Procedure 0%, DVT prophylaxis 5%, Signature 0%, Indication of procedure 55%, Anticipated blood loss (handwritten in WHO checklist), Details of tissue removed, added or altered 15% Conclusion: WHO checklist ensures documentation of important points. E-Documentation (ORMIS) plays an essential role & will foster increased compliance if the RCS outline is always used.

Biography :

Mina Aziz is working as a researcher at Aneurin Bevan University Health Board in united kingdom. He is also a trust member in the South Tees Hospital, NHS Foundation trust. He has published many articles in the reputed journals.