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Workstream 2a - Development of structured electronic operative records

When a child undergoes an operation, surgeons write a description of what they have done during the operation, both as a legal record, and also to allow other surgeons to understand what has been done in case further treatments are needed. In some hospitals, this operation record is written by hand, whilst in others it is written electronically, using an Electronic Patient Record (EPR) system. Currently however, there is little standardisation to either the paper of electronic operation records.

The aim of workstream 2a is to develop a standardised, structured, electronic operative record (EOR) for each of the six conditions that are included in the initial CSOR programme. Information will be collected from surgeons at hospitals around the UK about the information that they currently record in their operation notes for each of the conditions included in CSOR. A central group of surgeons will then review this information and use it as the basis for development of the EORs. Each EOR will pass through an iterative process of development, testing and revision. The final EORs will predominantly utilise multiple-choice questions, drop down menus, and single select questions as opposed to free text, so that there is clarity in the data that is being recorded. These EORs will be designed in such a way as to capture information about all of the steps of the operation that could potentially affect whether a child has a good or poor outcome following the operation. Once developed, these EORs will be made accessible from each hospital's EPR system. Surgeons will then start to use them to describe the operations they have performed.

Once developed, the EORs will be utilised by CSOR in two ways. Firstly, when a surgeon completes an EOR for a child whose parents have consented for their data to be used in the CSOR programme, this will notify the central CSOR database that another case has been identified and will establish a link between that child's EPR record and the CSOR database. Secondly, completion of the EOR will provide the CSOR database with all of the data that is required to understand in detail what operation a child has undergone, and what 'surgical' factors may potentially affect their outcome. Using EORs in this way will provide the most robust way of CSOR identifying cases and collecting relevant operative information.

Updated: Thursday, 01 April 2021 12:26 (v4)