1160 Improving Operative Notes and Consent Forms in a Urology Department Working Across Four Hospitals; a Quality Improvement Project

Abstract

Abstract Aim Consenting patients appropriately and well-written operative notes are essential for patient care. Anecdotal evidence highlighted that both of these areas could be improved in a urology directorate working across four hospitals. This QIP aimed to assess if consent forms included the risks stated by the British Association of Urological Surgeons (BAUS) leaflet for each operation and compliance with Royal College of Surgeons (RCS) guidelines for operative notes. Method A QIP using PSDA methodology. Cycle one: a retrospective assessment of one week’s operations assessing compliance of consent forms and operation notes. Cycle two: creating electronic templates for common operative notes which meet all RCS standards and consent forms as per the BAUS leaflets, followed by assessing their implementation for one week’s operating. Results Cycle one: 7% of consent forms were filled out appropriately. 0% of operative notes met all the RCS guidelines; 6 sections had 0% compliance. Cycle two: 33% of patients were consented using the templates; 13% of patients underwent an operation for which no template existed. 29% of operations were filled out using the templates and met all RCS criteria. Qualitative assessment found that surgeons did not use the template as they did not know they existed or how to use them; surgeons using the templates reported they saved time. Conclusions Premade templates save time and improve the quality of documentation when employed appropriately. However, their uptake requires buy-in from colleagues and teaching to ensure people know how to use them. Additional cycles are required to improve standards further.