SP4.7 Improving the documentation of breast surgery operation notes: Closing the loop on a quality improvement project

Abstract

Abstract Aims The operative note is an important document for ensuring patient safety and effective communication between the MDT. This quality improvement project (QIP) audited the completeness of the breast surgery operative note against the recommendations outlined in the Association of Breast Surgery (ABS) Summary Statement (2015). We developed an operative note proforma to address the deficiencies identified and evaluated the effectiveness of this tool. Methods 31 operative notes were retrospectively reviewed in our baseline audit (cycle 1) against the recommendations. We audited 17 parameters per note. Questionnaires were also circulated amongst 8 of our nursing colleagues to gather their feedback on the current operative note. An electronic proforma was devised from published recommendations and MDT feedback. We performed a prospective re-audit (cycle 2) of 33 notes following our intervention. Results Our baseline audit (cycle 1) identified that 7/17 of the parameters failed to meet the audit standard. 61% (19/31) of the operative notes were electronic. 63% (5/8) of our nursing colleagues agreed the handwritten operative notes were often illegible and all preferred an electronically written document. 1/17 of the parameters failed to meet the audit standard in the re-audit (cycle 2) post-intervention. 97% (32/33) of the notes were electronic and 52% (17/33) was documented using the proforma. Conclusions This QIP has demonstrated that improvements in the operative note documentation can be achieved through simple interventions. The proforma has been uploaded onto the local intranet for universal access. The outcome of this QIP is likely to be sustained by our departmental surgeons as documentation now meets recommended standards.