SP7.10 Laparoscopic Cholecystectomy Operation Notes (LaCON) Quality Improvement Project

Abstract

Abstract Aims Accurate and comprehensive operation notes are essential for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy is a common procedure where the quality of operative documentation can impact future patient care. The LaCON project aims to evaluate and improve the quality of LC operation notes with a view to implementing a novel software for standardised operation note creation. Method We retrospectively reviewed operation notes of LCs performed at our institution between August and November 2022. Electronic notes were assessed against the Royal College of Surgeons' Good Surgical Practice standard, consisting of 18 items. Results We assessed a total of 80 operation notes. There was 100% compliance in surgeon's name, operation name, incision, port placement, and closure technique. High-scoring items included indication (98%), operative findings (98%), operation date (91%) and assistant's name (90%). Among the lowest-scoring items were detailed postoperative instructions (46%), designation as elective or emergency (38%), intraoperative complications-problems (36%), additional procedures performed (23%), operative diagnosis (16%) and estimated blood loss (8%). Conclusions We identified several areas for improvement in LC operation notes. The next step of the LaCON project is to standardise operation notes by implementing an evidence-based standardised proforma for LC. This will be accessible through an online app that integrates with our hospital's electronic record system. It will also allow the extraction of operative data for research and audit purposes. This integrated online system has the potential for wider distribution across other procedures, specialities and centres to ensure high standards of safety and care and enhance collaborative multi-centre research.