Addressing the challenges around surgical documentation

surgeon

As NHS organisations work through the backlog of elective surgeries postponed during the last peak of the Covid-19 crisis, it is hugely important to ensure surgical departments are maximising efficiency where possible, while maintaining the quality and safety of the care they deliver. Documentation has a large part to play in this and is key to a smooth patient journey across services, as well as enabling the monitoring and benchmarking of performance at both surgeon- and trust-level.

Nuance has published a paper exploring the administrative workflow around surgical procedures and the challenges involved in this, focusing specifically on the procedure note and data submission to registries. Through research, interviews, and an online survey, we found surgeons regularly encounter many inefficiencies in their current processes.

The most significant of these is the duplication of information across different forms of documentation and systems. The lack of data flow between systems can mean information must be entered twice or transferred manually between different records. Additionally, a lack of alignment between registry data forms and procedure note templates can mean having to access multiple systems and records to find information, which is time-consuming and a source of frustration for many surgeons.

There is large variation in the methods used and the time spent to complete documentation. Some surgeons are averaging around 3-4 minutes on their procedure note, while for others this task can take up to 20 minutes. This range is due to a number of factors but is predominantly owed to the different methods surgeons use to record their notes. The most common methods are handwriting, dictation, typing freeform, and completing electronic template forms.

These processes appear to rarely strike a balance between quality and efficiency. Nuance’s online survey of 99 surgeons found that more than 50 per cent were not using any software in their note creation and, where software is in place, speed and ease of use varies greatly. Some interviewees indicated slow software means it can be quicker for them to handwrite notes, but previous studies have shown that handwritten notes often fail to meet the quality standards set by the Royal College of Surgeons of England. Electronic templates are of a more consistent quality but can be slow to locate and load.

Our report shows there are many influential elements determining the speed and quality of procedure notes and data submission, and so there can be no single solution. Based on these findings, we have produced a set of recommendations within the report to help surgeons, trusts, and registries improve the efficiency and quality of documentation processes. These include increasing interoperability, the use of speech recognition software, and greater surgeon input.

Technology has the potential to help eliminate unnecessary repetition and, importantly, reduce the time surgeons are spending on administrative tasks, if developed with a real understanding of consultant workflow and responsibilities. Processes are unique to each organisation and specialty, so trusts should take the time to evaluate where the pain points are for their surgeons and what will be of most value when it comes to driving improvement.

Download and read the paper ‘Addressing the challenges around surgical documentation’.

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About Dr Simon Wallace

Dr Simon Wallace is the Chief Clinical Information Officer (CCIO) of Nuance’s Healthcare division in the UK and Ireland. Simon has worked as a GP, hospital and public health doctor in Brighton and London. His interest in health informatics began in the 90s when he spent a year at the King's Fund investigating the impact of the internet on shared decision making between patients and their healthcare professional. For the past 15 years, he has worked for a range of organisations including Bupa, Dr Foster, Cerner Corporation and GSK across a range of technologies which include electronic patient records, telemedicine, mobile health and lifestyle devices. Simon has a keen interest in the voluntary sector, recently completing a 7 year term as a Trustee for Fitzrovia Youth in Action, a children and young people’s charity based in London.