901 Assessing Adherence to RCSEng Standards for Operation Notes in Patients With Neck of Femur Fractures: A Closed Loop Audit

Abstract

Abstract Aim To determine the accuracy with which Royal College of Surgeons of England (RCSEng) standards for documenting surgical procedures were met within a defined patient group, with the goal of improving patient safety, and improving documentation for medicolegal purposes. Method We conducted a closed loop audit on adherence to RCSEng standards for operation notes. We calculated the percentage adherence for each measurable standard and overall note, and presented the data at a local clinical governance meeting. We implemented autotext templates for operations to improve quality of operation notes in following RCSEng standards. We collected data retrospectively after 3 months to complete the audit cycle. Results We included 24 patients in the first cycle and 16 patients in the second cycle. Prior to intervention, the overall percentage of measurable standards met was 69.4%, which increased to 76.4% after intervention. The five least adherent standards all improved in percentage, with the largest increase from 33.3% to 93.8%. Conclusions In the first cycle, 3 of the measurable standards were met 100% of the time, which increased to 4 in the second cycle. Along with the general improvement of standards met, the interventions improved patient safety and surgeon documentation. Operation notes using templates generally recorded higher percentages of standards met than those without templates, but further work is needed to ensure more standards meet the 100% ideal.