SP11.11 Getting It Right First Time (GIRFT): An Audit of General Surgical Documentation in a District General Hospital

Abstract

Abstract Aim Getting It Right the First Time (GIRFT) has released national guidance regarding operation documentation for common general surgical procedures, namely laparoscopic appendicectomy, laparotomy & laparoscopic bowel resection surgery, laparoscopic cholecystectomy and inguinal hernia repair. This audit sought to assess compliance in a single District General Hospital Surgical Department. Method Retrospective analysis of operation notes was undertaken for consecutive cases. The audit included 25 laparoscopic appendicectomy, 25 laparoscopic cholecystectomy, 10 laparoscopic inguinal hernia, 20 open inguinal hernia and 10 laparotomy/laparoscopy with bowel resection procedures. Cases were included from a range of Consultants (range: 4 for laparoscopic inguinal hernia to 9 for laparoscopic appendicectomy). Operation notes were compared to the GIRFT guidelines. Results Overall compliance was 36% for open inguinal hernia, 44% for laparoscopic cholecystectomy, 45% for laparoscopic inguinal hernia, 54% for laparoscopy/laparotomy with bowel resection and 56% for laparoscopic appendicectomy. Notable areas of poor compliance included documentation of achievement of the critical view of safety in laparoscopic cholecystectomy (28%), if the appendiceal base was healthy in appendicectomy (60%), if the ilioinguinal nerve was protected or divided (35%) or if the vas deferens/testicular vessels were protected (50%) in open inguinal hernia repair and post operative oral intake status after bowel resection (80%). Conclusions Overall there was poor compliance between the operation notes and the GIRFT guidelines. These can potentially jeopardise the position of the surgeon and Trust during medicolegal claims. Use of standardised pre-populated electronic operation notes will be introduced Department-wide and compliance re-audited.