377 A Quality Improvement Project to Improve the Documentation of Post-Operative Complications on Discharge Documentation of Patients Undergoing Elective Colorectal Surgery at a Tertiary Centre

Abstract

Abstract Aim To improve the documentation of post-operative complications on discharge letters following elective colorectal surgery. Method Notes were retrieved for patients undergoing elective colorectal surgery and who were discharged in the month of August 2021. Notes were retrospectively analysed and complications occurring in the post-operative course were documented and cross-checked with discharge documentation. Summary statistics were used to summarise and compare inpatient complications vs discharge documentation of complications. A proforma was created to aid juniors in summarising inpatient complications and to be utilised as a reference for completing discharge documentation. A one-month period of using the proforma was trialled and data was re-collected to assess for improvement in discharge documentation. Results A total of 17 patients were discharged in August 2021 and suffered a total of 72 complications. Complications ranged from minor electrolyte disturbances to requiring operative intervention for anastomotic leak. Of the 72 complications only 28/72 (38.9%) were included (range 0-100%). The proforma for documentation was trialled for one-month and included a total of 18 patients suffering from 46 complications. Of these 46 complications a total of 31 (67.4%, range 50-100%) were documented on discharge letters. No major complications were missed when utilising the proforma. Conclusions Utilisation of a proforma to aid in documentation of complications on discharge has markedly improved the accuracy of discharge documentation. Further work is required to assess barriers to completion and to further improve the accuracy of discharge documentation.