O.R. Procedure Notes for Surgical Documentation and Synoptic Reporting

Team
Medical Informatics

Summary

The O.R. Notes project is similar to the discharge summary application as it is also a web-based application that is integrated with the UHN’s electronic patient record system. Electronic tools are efficient method for improving the quality of content, accuracy and timeliness of discharge summaries. O.R. notes are used to document the operating room procedures that may be done.

Abstract

Currently physicians do not have any electronic tools available to them to capture/input OR/Procedure Notes. Many of these physicians continue to dictate standardized notes and we anticipate that in some areas departments have independently developed independent alternative solutions to meet their electronic needs.

The purposoe of this project is to provide UHN’s physicians with an electronic tool to create online OR/Procedure notes. This will reduce current transcription volumes, improve coding and chart completion requirements, while improving access to usable electronic data for patient care, research and organizational planning.

It supports UHN’s strategic goals:

  • Integrate clinical information into patient-centric, profession-specific views
  • Capture clinical documentation in discrete, structured formats
  • Provide secure access wherever clinical information is required
  • Provide tracking and reporting capabilities to allow management to align operational decision-making with the strategies of the organization