390 Assessing the Standard of Operative Notes Within a Vascular Surgery Department: An Audit Cycle

Abstract

Abstract Aim Both the General Medical Council and Royal College of Surgeons of England’s (RCSEng) ‘Good Surgical Practice’ state that all clinical documentation must be recorded clearly, accurately, and legibly. The operative note is not just a means of communicating post-operative plans but can also be used for medico-legal purposes. The aim of this audit cycle was to ascertain how well the operative notes within a Vascular Surgery department adhered to the guidelines devised by RCSEng. Method 40 operative notes were analysed prospectively against the criteria stated in the ‘Good Surgical Practice'. The surgeons were made aware of the initial results via a departmental meeting. Using the Plan-Study-Do-Act (PDSA) model, we studied the pre-existing operative note template and created an aide-memoire highlighting the criteria with poor compliance. This was placed in all the vascular theatres. A re-audit was then undertaken 2 months after. Results In the first audit, we noted good compliance in areas that were included in the pre-existing template such as date (97.5%), name of operator (97.5%), name of anaesthetist (100%), operative procedure (100%), and closure technique (95%). Areas in need for improvement included time (0%), anticipated blood loss (2.5%) and elective/emergency procedure (10%). The second cycle demonstrated improvements (100% compliance) in most parameters. Documentation of time, elective/emergency procedure, and legibility showed minimal improvement. Conclusions This audit highlighted the importance of greater awareness of the expected standard of note documentation. Implementation of proformas and electronic documentation can effectively circumvent issues related to variability and legibility, and ultimately improve patient safety.