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Table 2 List of 29 core standards, with comparison of handwritten and typed operation notes

From: Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals

Core standards Overall % Range % N/A Handwritten % Typed % Chi-squared p value
1. Available on ward 87.8 44.3–100 - 94.9 83.9 <0.0001
2. Date 99.0 96.2–100 - 98.8 99.5 0.185
3. Time 25.3 1.1–91.3 - 19.4 36.5 <0.0001
4. Legible 97.9 93.2–100 - 96.5 99.8 <0.0001
5. Patient identifiers 97.6 83.7–100 - 95.7 99.8 <0.0001
7. Surgeon named 99.3 96.6–100 - 99.0 99.5 0.312
8. Assistant named 80.5 57.9–97.5 2.7 76.3 77.8 0.007
9. Anaesthetist named 79.9 42.4–95.2 3.2 78.5 78.6 0.110
10. Anaesthetic given 60.9 35.6–85.2 - 58.1 68.3 <0.0001
11. Consultant responsible 73.6 37.1–97.6 - 72.2 74.0 0.510
12. Diagnosis 76.3 57.6–98.8 - 70.1 76.1 0.026
13. Operation named 99.2 97.4–100 - 99.4 98.8 0.345
14. Patient position 56.8 37.3–77.8 - 47.4 64.3 <0.0001
15. Incision/Approach 90.0 76.7–98.8 1.4 86.1 93.2 <0.0001
16. Exposure 52.8 18.6–73.9 4 52.1 53.4 0.75
17. Elective/Emergency 23.2 0.5–52.3 - 30.1 23.5 0.015
18. Findings described 80.1 59.8–93.8 - 68.9 88.6 <0.0001
19. Additional procedures performed and why 50.5 27.1–75.0 1.5 42.9 56.7 <0.0001
20. Tissue removed/added/altered 62.0 31.7–87.7 - 46.4 71.5 <0.0001
21. Prosthesis 47.9 31.7–87.7 41.1 43.4 47.6 0.209
22. Serial no of prostheses 18.1 0–72.8 41.1 11.0 6.6 0.006
23. Serial no of prostheses recorded elsewhere 42.1 5.4–78 41.1 37.2 42.5 0.224
24. Complications described 20.6 0–79 - 16.6 18.2 0.486
25. Closure 81.0 7.6–97.5 3.5 89.0 89.4 0.184
26. Postop instructions 97.6 89.4–100 - 94.5 99.7 <0.0001
27. Antibiotics 53.1 42.6–79.7 - 48.7 50.6 0.530
28. VTE prophylaxis 50.6 40.9–67.8 - 45.6 51.4 0.056
29. Signature 81.9 2.5–100 - 95.1 60.2 <0.0001