Operating theater books contain detailed records of surgical procedures and patients, which are used for planning and ordering supplies. These confidential records provide information on patient care journeys. Traditional paper-based operating theater books included patient names, ages, addresses, diagnoses, attending medical staff, dates and times of operations, and anesthetics used. While some organizations still use handwritten records, computer-based systems provide more secure, efficient access to records for medical staff in emergencies. Computer networks allow records to be easily accessed from any location in the hospital and save medical personnel time retrieving files. Computerized records also improve patient care, safety, and decision making.

1. RECORD KEEPING IN OPERATION
THEATER
USE OF COMPUTER IN RECORD
KEEPING

2. DEFINATION
An operating theatre book is essential: it contains
detailed records of the patients operated on and the
surgical procedures performed. This is useful
information for planning and ordering supplies. All
information in the operating theatre book is
considered to be confidential.
The purpose of records is to provide a clear precise
account of the patient healthcare journey and reflect
the practitioners assessment ,planning , and
evaluations processes.

3. Full description
These registers were used to provide an ongoing
record of patients that had undergone surgery at the
hospital, and include the following information:
- Patient Name
- Age
- Address
- Diagnosis
- Names of attending doctors, assistants, and
anaesthetists
- Date and time of operation
- Anaesthetic used.

5.  Types of record keeping :
 Hand written records
 Computer based records
 Some organisations or employers will use a combination of
both.
 Component of a patients record include :
 Medical record
 Nursing records/progress notes
 Medication chart
 Laboratory reports
 Vital signs /observation

6. Use of compute for record keeping
 A computer network is a far more secure way to store and
organize patients record. Filling patients record in cabinetes or on
shelving is quickly being phased out, with computer system
offering a more efficient solution.
 Teaditional filling system is problemetic . In an emergency ,
medical staff needs fast access to patient records.
 A computer keeps patient record secure ,organized and easily
accessible.
 A mobile computer cart gives doctor nurses access to record
anywhere in the hospital.
 There is no need for medical personnel to waste time running back
and forth to retrieve patients file when they easily transport a
laptop computer with network access.

9.  Purpose of record : provides information on clients medical
conditions, socio economic, psychological and environmental factors.
Data for program planning and evaluation. Plan for future. Evaluation
of services and research.
 Advantages of computer based record system :
 Information can be used and shared fastly
 Save time and improve patient care
 Could be accessed independently
 Can be integrated with other initiative
 Increased patient safety
 Shared decision making
 More efficient , accurate transferability of records.

10. Thank you