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Documentation of surgical procedure

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  • 1. Documentation of surgicalprocedure : Why & HowHieder A’ala
  • 2. Why Documentation and archieving Reviewing the effectivness of training Recording the wired cases Matter of education through case-based approach
  • 3. How …. Criteria of good documentation Objective data…not subjective Honesty in writing. Continuity Postoperative follow up Good classification of the surgery undertaken Ability to find the procedure without delay Commentary ( on the procedure which was read prior to procedure ) other than descriptive.
  • 4. methods 1.Program-based 2.Written work 3.Web-based 4.Media
  • 5. 1. Program based The European Neurosurgical Electronic Logbook of Operations
  • 6. 1. Program based…cont. Electronic version of this logbook that helps the trainee to record all operations in an easy and fast way. Runs under any version of Microsoft Windows The EANS published a detailed list of operations with minimum and optimum figures for each entry that a trainee must meet at the end of his training It is not depended on any external programs
  • 7. Continue The application is designed to support multiple languages for all text messages and the list of diagnoses For security reasons all data entered is encrypted To allow multiple users to access their data on one single computer, the application supports an unlimited number of accounts that can be accessed by one installation of the program
  • 8.  Installation of the application is as straightforward as installing other standard applications Both lists mentioned can be printed
  • 9. Role of the trainee during the operationThis value can either be “T” , “TS”, “C” or “A”: T=Trainee: The trainee has done the operation. The supervising consultant must not have made a decision/practical manoeuvre significantly affecting the execution of the operation. TS=Trainee (+Consultant Supervising): The trainee has done the operation but the supervising consultant has made a significant decision/practical manoeuvre during the operation.
  • 10.  C=Component: The trainee has performed component parts during the operation under supervision of a senior surgeon: Positioning, operative approach, closure, drainage, draping, instructions for postoperative care. A=Assistant: The trainee is the principal assistant during the operation.
  • 11.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 12.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 13.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 14.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 15.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 16.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 17.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 18.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 19.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 20.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 21.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 22.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 23.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 24.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 25.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 26. 2.Formal written The eldest way to record Depends on ability of recorder to fullfil all fields Obligate us to read prior to write Nothing not important, keep your mind with the seniors and register every data
  • 27. 2.Formal written Not comfortable All data around us recorded by new technologies Return to previous cases is not so easy
  • 28. 2.Formal written writtenMy Real LogbookTrauma Cranial sheet.doc
  • 29. 2.Formal written ..cont.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 30. 3.Web-based Few sites were constructed for such mission The data is stored in place other than my computer Revision and recording need internet access The available site is not free Well organized data and fields, no place for blurred subjects and specific.
  • 31. continue The web facilitate revision with trainer Accredited from well known organisation.
  • 32.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 33.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 34.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 35.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 36.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 37.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 38.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 39.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 40.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 41.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 42. 4.Media Advantages : Audio recording represents one of the old method to record Video and photos capturing are new quit methods to save pt. pictures and operative steps
  • 43. 4.Media Disadvantages : Continuity not always possible Needs tool ( high cam zooming ) Needs someone to capture them Microscopic recording is the best
  • 44. 4.Media Example : method 1 folder of pics and sound file
  • 45. 4.Media Example :
  • 46. 4.Media Example :
  • 47. 4.Media Example : method 2 microscope recording
  • 48.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  • 49. The Final WordBe honest with your data
  • 50.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level