1503 Review of Electronic Theatre Coding System & Documentation of Neurosurgical Activity

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Abstract Introduction It was noticed that the current electronic theatre coding system was limited in its reflection of departmental theatre activity and discrepancies in discharge letters compared to the actual operations performed. To prevent this from recurring, a standardised neurosurgical operation note was developed, and an audit of the electronic coding system was undertaken to see if the correct operation matched that of the code listed. Method A 6-month retrospective analysis from March to September 2020 was completed using the electronic theatre coding system, patients’ electronic records and the patient handover list. Results 232 operations performed and only 10.3% of procedures were correctly coded by the current coding system. 11 operations were not on the theatre system although performed in theatres. The current system only coded for 82 procedures and did not show the full range of operations. There was wide variety of operation notes and only 185 operation notes were found on the patients’ electronic record. Frequently the procedure was not clearly identified so juniors relied on the inaccurate electronic code on the theatre list for the patients’ operation hence explaining the problem identified in discharge letters. Conclusions A new coding list for the electronic theatre system was created with 228 procedures divided into correct subcategories. A standardised template for operation notes was also developed and implemented so that full neurosurgical departmental activity is reflected, and accurate discharge letters are completed so that complete data collection can be done for audit purposes.