EP-584 An evaluation of plastic surgery operation note documentation in line with RCS standards

Abstract

Abstract Aim To assess the extent to which operation note documentation had been completed accurately, in line with Royal College of Surgeons (RCS) standards, in a local plastic surgery department. Methods Using an RCS good surgical practice guideline, operation notes from cases in January 2021 were reviewed. A total of 112 procedures that were undertaken in both theatres and plastics dressing clinic were audited. The results were collated and analysed using Microsoft Excel. As a result of data analysis, interventions were created whereby results were presented at a local meeting and guidelines were disseminated via WhatsApp to members of the surgical team. A re-audit then occurred using all plastic surgery procedures in May 2021, totalling 112 patients again. Results The first cycle demonstrated that the majority of the guideline subsections were met well. This included a defined operative diagnosis (96% of notes) and operative findings (97% of notes). However, some guidelines including problems/complications (17% of notes) and DVT prophylaxis (0.01% notes) were not adhered to as appropriately. The re-audit concluded that nine subsections of the guideline improved from the first cycle. This included operative diagnosis (96% first cycle, 100% second cycle) and details of closure technique (81% first cycle, 95% second cycle). Notably problems/complications (17% first cycle, 41% second cycle) also improved. Conclusions Initially, the guideline was met to a reasonable standard, however, improvements were made following the intervention. This led to an improvement in the documentation of nine subsections of this guideline.