515 Operative Documentation Audit of General Surgery

Abstract

Abstract Introduction Documentation is an important part of healthcare practitioners’ daily routine. The importance of documentation is well stress in the literature and by the GMC's good medical practice. Good documentation ensures patients receive the best possible clinical care. Recently, the Royal College of Surgeons (RCS) published guidance aiming to improve the reported poor quality of operative documentation. Method The RCS operative notes guidelines were used as the audit criteria. These guidelines consisted of 19 domains and the adherence of the general surgery department operative documentation to each of these domains was measured. A 100% adherence to the RCS guidance was set as the audit standard. Data was collected during a period of four weeks from a set of General Surgery patients under the care of a random range of consultant surgeons. Results Data from 50 general surgery patients between 13/10/21 and 04/11/2021 were analysed. 47% of the 19 documentation domains stated by the RCS had 100% adherence. In addition, only 4% of the 50 patients’ operative notes had 100% adherence to all the 19 domains specified by the RCS. Conclusion Current operative notes documentation in the general surgery department does not meet the standards of this audit. However, possible areas of improvement are identified to bring current practice closer to the RCS operative notes guidance.