Documentation of surgical procedure

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Documentation of surgical procedure

  1. 1. Documentation of surgicalprocedure : Why & HowHieder A’ala
  2. 2. Why Documentation and archieving Reviewing the effectivness of training Recording the wired cases Matter of education through case-based approach
  3. 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. 4. methods 1.Program-based 2.Written work 3.Web-based 4.Media
  5. 5. 1. Program based The European Neurosurgical Electronic Logbook of Operations
  6. 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. 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. 8.  Installation of the application is as straightforward as installing other standard applications Both lists mentioned can be printed
  9. 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. 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. 11.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  12. 12.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  13. 13.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  14. 14.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  15. 15.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  16. 16.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  17. 17.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  18. 18.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  19. 19.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  20. 20.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  21. 21.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  22. 22.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  23. 23.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  24. 24.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  25. 25.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  26. 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. 27. 2.Formal written Not comfortable All data around us recorded by new technologies Return to previous cases is not so easy
  28. 28. 2.Formal written writtenMy Real LogbookTrauma Cranial sheet.doc
  29. 29. 2.Formal written ..cont.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  30. 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. 31. continue The web facilitate revision with trainer Accredited from well known organisation.
  32. 32.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  33. 33.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  34. 34.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  35. 35.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  36. 36.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  37. 37.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  38. 38.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  39. 39.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  40. 40.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  41. 41.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  42. 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. 43. 4.Media Disadvantages : Continuity not always possible Needs tool ( high cam zooming ) Needs someone to capture them Microscopic recording is the best
  44. 44. 4.Media Example : method 1 folder of pics and sound file
  45. 45. 4.Media Example :
  46. 46. 4.Media Example :
  47. 47. 4.Media Example : method 2 microscope recording
  48. 48.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level
  49. 49. The Final WordBe honest with your data
  50. 50.  Click to edit Master text styles  Second level  Third level  Fourth level  Fifth level

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