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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