The document discusses documentation of surgical procedures and methods for documentation. It notes that documentation is important for reviewing training effectiveness, recording complex cases, and education. Good documentation criteria includes objective data, honesty, continuity, and postoperative follow-up. Methods of documentation include program-based electronic logbooks, formal written records, web-based systems, and use of media like audio, video, and photos. Trainees should accurately document procedures and be honest in their reporting.

1. Documentation of surgical
procedure : Why & How
Hieder 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 operation
This 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.

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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.
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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.

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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

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49. The Final Word
Be honest
with your
data

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