684 The Standard of Emergency Operation Note Documentation at A District General Hospital Compared Against The Royal College of Surgeons of England (RCSEng) Standard

Abstract

Abstract Introduction Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma. Method A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020. Results RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p < 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p < 0.0001), estimated blood loss (2% vs 63%; p < 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p < 0.0001). Conclusions Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.