Optimizing knee arthroscopy documentation using a new template

Abstract

Introduction: The purpose of the study was to assess the quality of documentation of knee arthroscopy and evaluate the implementation of a novel operative template.

Method: A 34-point assessment was undertaken based on published national guidelines. A retrospective study of 50 operative notes of patients (group A) undergoing knee arthroscopy was completed. A new operative note template was devised to include important criteria and assessed in 49 patients (group B) for its efficacy in providing appropriately detailed findings.

Results: Group A was lacking the minimum essential documentation standards expected. Some essential criteria for arthroscopic procedures were as low as 4%. Group B showed a statistically significant increase (P<0.001) in documentation accuracy throughout the essential criteria compared to the findings in group A.

Conclusions: The authors conclude that the use of an evidence-based operative template for knee arthroscopy significantly improves the quality and accuracy of documentation compared to conventional free-hand operative notes.