TU8.4 Standard of Operation Notes in General Surgery

Abstract

Abstract Aims To assess the quality and precision of operation notes, as well as, ensure that they were written in accordance to requirements and standards set by the Royal College of Surgeons England as stated in “Good surgical practice”. Method It was a retrospective local audit and re-audit of patients admitted under the General Surgery department where 50 & 30 patients were selected randomly in May 2021 and October 2021 respectively. Data was extracted from applications on secure trust servers and analyzed on Microsoft Excel with patient information carefully anonymized. To establish the standard of best practice for this audit, guidelines published in The Royal College's “Good Surgical Practice” were used to devise a comprehensive list of criteria that should be present on every operation note. These can be found at: http://www.rcseng.ac.uk/standardsandguidance. Results The results of the initial audit were compared with that of the re-audit. Significantly noted in the re-audit, was the 50% improvement in documentation of criteria such as the name of anesthetist, anticipated blood loss, operative diagnosis, and antibiotic prophylaxis. There was also more clarity in the documentation of post-op plans in the re-audit (e.g duration of post-op antibiotics/VTE prophylaxis and wound care) for each patient as recommended in the initial audit. Conclusion The improvement in clear and precise documentation of operation notes noted in this re-audit helped to improve the quality and safety of patient care delivered. Further audits and re-audits, as well as, quarterly re-education of surgeons have been recommended to attain and maintain targets.