SP3.10 Improvement of quality of operation notes. An audit was performed to assess operation notes in our hospital, detected multiple points commonly missed in the operation notes as well as illegibility of some. Implementation of electronic operation notes took place to improve service

Abstract

Abstract Aim An audit was performed in November 2021 to assess completion of operation notes according to national guidelines. Methods 18 points were checked in accordance to Royal college of Surgeons guidelines. Results Percentage of completion ranged from 47% to 77% according to sub-specialty. Main points that were missed were time of operation, bloods loss and antibiotic prophylaxis. 29% of notes had illegible hand-writing which could not be read appropriately by two or more people. Electronic operation notes have been identified as the ideal plan to help avoid illegibility and to make sure all points are present. Multidisciplinary approach was done to implement electronic typed operation notes in the hospital involving surgical team, management, theatre staff and information technology (IT) specialist. This took place by providing extra computers in both elective and emergency theatres with appropriate software to allow for typed operation notes. Operation note templates were used to ensure all points are filled. Significant improvement in the operation notes was noticed once electronic notes have been used. The percentage of electronic notes went up from 9% to 34% in January 2023, legibility increased from 71% to 96%, time of operation documentation increased from 0% to 22%. There was 100% compliance each of the following; name of surgeons, mode of surgery, date of operation, operative procedure, operative findings and closure technique. Overall completion rate of operation notes improved from 72% to 82%. Conclusion it is inevitable that technology can be used to eliminate human error, provide clear documentation and create traceable information.