EGS P29 Improving Quality of Operation Notes in General Surgery – A complete audit cycle

Abstract

Abstract Background Good quality of operation notes are essential for good post-operative care, patient safety and medico-legal issues. RCSEng have guidelines on items that should be included in all operation notes. RCSEng Guidelines state: Ensure that there are clear (preferably typed) operative notes for every procedure. The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. We re-audited the quality of operation notes in general surgery. Methods We re-audited and compared the results with the first cycle. Four months (1st August to 30th November 2021) period of consecutive operation notes were reviewed. Operation notes for endoscopy were excluded. Operations notes were analysed for documentation of the items as per RCSEng guidelines. There were less operations post COVID-19, hence longer study period. After first cycle, departmental presentation given for education and posters displayed in theatres as reminder. Initial plan for 2nd cycle in 2020 but it was not possible due to COVID-19. Problems/complications, extra procedures and prosthesis used were not included. Additional criteria reviewed was: type of anaesthetic, patient position, indication for procedure and ASA grade. Results A total of 239 operation notes were identified. 169 emergency and 70 elective cases. 193 were handwritten and 46 were typed.The results were compared to the first cycle: Conclusions Higher proportion was of emergency procedures during the 2nd cycle. Also, higher proportion of handwritten notes during 2nd cycle. There was improvement in documenting elective/emergency, time, type of anaesthesia, indication, position, operative findings/diagnosis, details of tissue removed/added/altered, blood loss, antibiotics, DVT prophylaxis. However, there was poorer documentation of date, name of assistant, incision, closure, signature remains. Ongoing education of the surgeons is vital to improve the quality of the operation notes. We suggest addition of further headings on the current op-note as aid-memoire and introduction of digital operation notes.