A Pilot Study of Electronic Cardiovascular Operative Notes: Qualitative Assessment and Challenges in Implementation

Journal of the American College of Surgeons

Volumn 210, Issue 2, 2010, Pages 178-184

  Brown, Morgan L ^a   Quiñonez, Luis G ^b   Schaff, Hartzell V ^c  

^a UNIVERSITY OF ALBERTA   (Canada)

^b STOLLERY CHILDREN S HOSPITAL   (Canada)

^c MAYO CLINIC   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AORTA VALVE REPLACEMENT; ARTICLE; CARDIOVASCULAR SURGERY; CORONARY ARTERY BYPASS GRAFT; ELECTRONIC MEDICAL RECORD; ELECTRONICS; INFORMATION PROCESSING; PILOT STUDY; PRIORITY JOURNAL; QUALITY CONTROL; REOPERATION;

CARDIAC SURGICAL PROCEDURES; COHORT STUDIES; ELECTRONIC HEALTH RECORDS; FORMS AND RECORDS CONTROL; HUMANS; INTRAOPERATIVE PERIOD; OPERATING ROOM INFORMATION SYSTEMS; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE); PILOT PROJECTS; PROGRAM EVALUATION; RETROSPECTIVE STUDIES;

EID: 74749100259     PISSN: 10727515     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.jamcollsurg.2009.10.009     Document Type: Article

References (17)

1. Moulinier C.B. The standardization program of the American College of Surgeons. Surg Gynecol Obstet 34 (1922) 141-160
2. The Royal College of Surgeons of England. Professional standards and regulations (2008), Latimer Trend & Company Ltd, Plymouth, England
3. Joint Commission. Information management. http://www.jointcommission.org/AccreditationPrograms/Office-BasedSurgery/Standards/09_FAQs/IM/Operative_Reports.htm Accessed April 17, 2009
4. The Society of Thoracic Surgeons. STS Adult Cardiac Surgery Database, v2.61. http://www.sts.org/sections/stsnationaldatabase/datamanagers/adultcardiacdb/datacollection/index.html Accessed April 17, 2009
5. Baker M.S., and Baker B.H. The operative report. Int Surg 61 (1976) 333-334
6. Rogers A., Bunting M., and Atherstone A. The quality of operative notes at a general surgery unit. S Afr Med 98 (2008) 726-728
7. Morgan D., Fisher N., Ahmad A., and Alam F. Improving operation notes to meet British Orthopaedic Association guidelines. Ann R Coll Surg Engl 91 (2009) 217-219
8. Flynn M.B., and Allen D.A. The operative note as billing documentation: a preliminary report. Am Surg 70 (2004) 570-574
9. O'Bichere A., and Sellu D. The quality of operation notes: can simple word processors help?. Ann R Coll Surg Engl 79 (1997) 204-209
10. Harvey A., Zhang H., Nixon J., and Brown C.J. Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control. Surgery 141 (2007) 708-714
11. Parkih J., Yermilov I., Jain S., et al. Do standardized templates improve documentation of quality of care?. J Surg Res 143 (2007) 158-163
12. Scherer R., Zhu Q., Langenberg P., et al. Comparison of information obtained by operative note abstraction with that recorded on a standardized data collection form. Surgery 133 (2003) 324-330
13. Laflamme M.R., Dexter P.R., Graham M.F., et al. Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports. AMIA Annu Symp Proc (2005) 425-429
14. Cowan D.A., Sands M.B., Rabizadeh S.M., et al. Electronic templates versus dictation for the completion of Mohs micrographic surgery operative notes. Dermatol Surg 33 (2007) 588-595
15. Pellegrini D.P., Raghu S., and Waechter D.K. Structured electronic documentation cardiac surgery and PowerNote-a pilot project. AMIA Annu Symp Proc (2005) 1076
16. Edhemovic I., Temple W.J., de Gara C.J., and Stuart G.C.E. The computer synoptic operative report-a leap forward in the science of surgery. Ann Surg Oncol 14 (2004) 941-947
17. Hogan W.R., and Wagner M.M. Free-text fields change the meaning of coded data. AMIA Annu Fall Symp Proc (1996) 517-521