EP 746 The Current Practice and Accessibility of Operation Notes at a DGH – A Push Away from Paper Copies and Towards Online Access

Introduction and Aim

Operation notes provide accurate and crucial information detailing intra-operative findings and procedures. When indicated, they also include useful guidance regarding post-operative instructions, restrictions, and follow-up. Access to operation notes is not standardised nationally, with hospitals using both physical and online documentation.

At our Trauma and Orthopaedics department in a DGH, current practice stands as operation notes being retained on Bluespier (theatre management system) with a physical copy printed and kept in the inpatient notes. These can be challenging to retrieve in clinics, future admissions, or for other future reference. This study aimed to understand the challenges of the current system and encourage online upload of the operation notes to the EPR.

Method

A questionnaire assessing the challenges of current practice was sent to healthcare staff (n=32). This included doctors, nurses, and the therapies team. A review of all operations in October, and the status of their op-notes was completed.

Results

31/32 staff members agreed that op-notes being included in the EPR would be advantageous, with 1 responder remaining indifferent. A total of 101 procedures were completed in October 2025, with 59/101 (58.4%) of op-notes being uploaded to the EPR

Conclusions

Moving towards a paperless hospital system, operation note accessibility on EPR should be higher.

There is an active movement in favour of dictated operation notes from the index surgeon. A future review of this ongoing effort, alongside a re-assessment of the current online/paper notes will be helpful in continued service evaluation and improvement.