HPB P49 Implementation of a standardised operation note template using the Getting It Right First Time (GIRFT) and Royal College of Surgeons of England (RCS) best practice guidance to improve the quality of laparoscopic cholecystectomy documentation

Abstract

Abstract Background Getting it right first time (GIRFT) in partnership with the Royal College of Surgeons of England (RCS) have published advice on aspects of surgery which should be documented in the laparoscopic cholecystectomy (LC) operation record. This is following calls to enhance the accuracy and value of operative records coupled with a lack of existing recommended minimal standards. Operation notes are fundamental for communication of patient care and in the review of operations following adverse events or patient complaints. Methods We reviewed 20 operation notes to assess adherence to the guidance. Some aspects of the guidance were omitted if expected to be documented elsewhere in the patient records, 28 of 32 points were reviewed. An operation note template was created and implemented then a further 20 operation notes were reviewed. Results Initially, the mean completeness of guidance items was 39%. 6 of the 20 operation notes documented that the ports were inserted under direct vision; 8 documented that a critical view of safety was achieved; 13 documented the spillage/non spillage of bile or stones; 16 documented removal of ports under direct vision and none included all aspects of the post-operative plan. Following implementation of the template, compliance improved across all items. Conclusions There is scope to improve the documentation of LC, particularly in areas linked to common intraoperative and postoperative complications. Implementation of a standardised operation note template is an effective way of improving the documentation of laparoscopic cholecystectomy.