Table 2.
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 |