Streamlined Operative Notes Save Time and Increase Accuracy

Ophthalmologists are crunched for time at all angles: as the aging population increases and the number of practicing surgeons remains stable, we are stretched further and thinner. Analog approaches to becoming more efficient (ie, reimagining a practice workflow to shorten patient visits without sacrificing quality) have worked for some clinics, but many surgeons feel like they’ve hit a ceiling on how efficiently they can operate.

Surgeons who leverage ZEISS VERACITY Surgery Planner in their OR have learned that the tedious, time-consuming task of generating, reconciling, and filing operative notes can be completed in a far more efficient manner if they lean on the latest technology. An added bonus: notes are more accurate, as the chances of the surgeon forgetting an important detail or a staff member mistakenly transcribing the wrong piece of handwritten data are effectively nil.

To see how ZEISS VERACITY Surgery Planner streamlines the generation of operative notes and increases their accuracy, let’s compare the analog and digital operative note processes.

Back when my OR used paper reports, handwritten surgical plans, and relied more on human transcription and calculation to transfer biometric data from the presurgical visit to the OR, the process for generating operative notes reflected our analog approach to surgery.

At the end of a surgical day, I reviewed a printed template used to document what occurred in each OR session. Some cases stuck to the template, and required little modification; others required heavy edits and adjustments to reflect the unique circumstances of a patient’s case. If, for example, I unexpectedly had to place the IOL in the sulcus during cataract surgery, I needed to ensure that I noted this event somewhere on the template. When I was done with my first round of notes, an employee printed out more specific versions of each operative note that included my modifications. I then spent time ensuring the finalized note had been adjusted properly before signing and filing the operative note.

In addition to being a tedious task, this methodology was fraught with opportunities for errors and inefficiencies. If, for example, my employee misunderstood my handwritten note, they had to return to their computer to correct the report and reprint a corrected version; there was also the chance that I would miss an improperly transcribed note, rending the operative note inaccurate. Further, because I performed all operative notes in a batch at the end of an OR day, there was the chance that I forgot to record an important variation in the patient’s surgery. If my third patient of the day coughed during surgery, for example, there was a decent chance that I forgot about it by the time a pile of paperwork reached my desk.

A digital approach to surgery and operative note capture eliminates the barriers that made analog note taking inaccurate, time-consuming, and tedious.

When performing surgery with ZEISS VERACITY, I review the surgical plan for the final time before surgery and then after surgery I shift my focus to documenting everything that happened in the OR for that particular patient. ZEISS VERACITY allows me to scan the barcode of the IOL while in the OR after implantation to be sure the record accurately reflects the lens we used in case the choice needed to be modified or otherwise. This change is also reflected automatically in the operative notes.

I still rely on a templated form as a starting point for generating operative notes, and I have pre-selected a series of checked boxes that describe routine case events. I uncheck those boxes if something didn’t occur during surgery, and check other boxes if something unexpected (but not unheard of) arose. If, for example, the patient unexpectedly needed carbachol during surgery, I check a box that describes that event. An area to enter unstructured data also exists, so if a patient sneezes during surgery, I simply type that detail into the operative note.

I immediately review the operative note in digital form while the details of surgery are fresh in my mind, and a few clicks of the mouse (or taps of the screen) later, my operative notes are complete. This adds maybe 10 seconds to each case—but saves me an hour at the end of the day and improves the quality of my operative notes.

If you’re like me, then every minute reclaimed on surgery days is precious. Smoothing the process of generating operative notes via ZEISS VERACITY Surgery Planner buys back time at the end of the day and ensures that notes are accurate and complete.

What you do with that time back is up to you. In my clinic, the full-time employee who was previously tasked with reconciling my handwritten notes and delivering printouts for my review has been reassigned to a more productive role. Other clinics may find that they can accommodate increased volume with this time back, and others may simply wish to add the time back to their personal life to achieve better work-life balance.

What you do with the time is up to you. Just know that ZEISS VERACITY Surgery Planner can be the key to earning back precious minutes to your day.

^{The statements of the author reflect only his personal opinions and do not necessarily reflect the opinions of any institution with whom he is affiliated.
The author has a contractual or other financial relationship with Carl Zeiss Meditec, Inc. and has received financial support.}