Comparing electronic recording with a diagrammatic template versus traditional handwritten recording of tympanomastoid procedures: third audit cycle of 95 cases

J Laryngol Otol. 2017 May;131(5):462-464. doi: 10.1017/S002221511700041X. Epub 2017 Mar 14.

Abstract

Background: The middle ear and mastoid are complex three-dimensional structures and therefore tympanomastoid procedures require detailed documentation. Traditional written accounts can be inaccurate and difficult to interpret.

Methods: This audit of 95 patients compares the completion of essential operative details using: an all-electronic version of a standardised proforma with a diagrammatic template, a non-electronic version with a diagrammatic template, and a traditional handwritten template.

Results: The electronic template resulted in 81 per cent of essential operative items being recorded, compared to 78 per cent (p = 0.3) with a previous non-electronic template and 50 per cent (p = 0.0004) when using simple handwritten recording.

Conclusion: An electronic proforma with a diagrammatic template improves the documentation and interpretation of tympanomastoid procedures compared to traditional handwritten records.

Keywords: Myringoplasty; Otolaryngology; Otological Surgical Procedures; Tympanoplasty.

Publication types

  • Comparative Study

MeSH terms

  • Documentation / methods*
  • Documentation / standards
  • Handwriting
  • Humans
  • Mastoid / surgery
  • Medical Audit*
  • Medical Records Systems, Computerized
  • Medical Records*
  • Otologic Surgical Procedures / methods*
  • Retrospective Studies
  • Tympanic Membrane / surgery