1129 LaCON: A Quality Improvement Project on Laparoscopic Cholecystectomy Operation Notes

Abstract

Abstract Aim Accurate and comprehensive operation notes are crucial for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy (LC) is one of the most common procedures in General Surgery, either in an Elective or Emergency setting. Therefore, there is a need for an accurate and standard way to document the operation notes for a safe immediate and late post-operative care, including follow-up. The LaCON project aims to evaluate and improve the quality of the operation notes. Method A retrospective review of operation notes of LCs performed at our institution between August-November 2022. Electronic notes were assessed against the Royal College of Surgeons’ Good Surgical Practice standard, consisting of 18 items. Results A total of 80 operation notes were reviewed. There was 100% compliance in surgeon’s name, operation procedure, incision, port sites, and closure technique. Other high-scoring items were indication (98%), operative findings (98%), operation date (91%) and assistant’s name (90%). Among the lowest-scoring items were detailed postoperative instructions (46%), designation as elective or emergency (38%), operative diagnosis (16%) and estimated blood loss (EBL) (8%). Conclusions We identified several areas for improvement in LC operation notes, such as a detailed and robust post-operative plan, a precise intraoperative diagnosis and information about EBL. The LaCON project highlighted the need to implement an electronic evidence-based proforma to standardise notes. This proforma will be accessible through a secure online app, in line with the local Hospital policies, and will allow accurate and contemporaneous record keeping and efficient extraction of operative data for analysis.