WP8.5 - Operative Documentation of Laparoscopic Appendicectomies at FVRH based on GIRFT - An Audit

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Abstract Introduction Laparoscopic appendicectomy (LA) is the most performed abdominal surgery in the UK. Clear documentation is required to ensure safe and effective patient care. Aims To assess compliance with LA operative documentation at Forth Valley Royal Hospital using Getting It Right First Time (GIRFT) guidelines. Methods 27 data points selected from GIRFT Guidelines were examined retrospectively for 172 LA procedures between 01/08/2022 and 29/09/2023. Completed numbers and percentages for each data point were calculated. Results Most consistently documented data points were intra-operative findings 168 (98%), details of closure 168 (98%) and method to secure appendix stump 161 (94%). Least consistently documented were drain insertion 7 (4%), estimated blood loss 5 (3%) and instructions for suture removal 6 (3%). 6 (37%) operative notes explicitly confirmed whether the appendix was removed in those with a macroscopically normal appendix. Conclusion Many data points had a high completion rate, whilst others had a low completion rate. We have highlighted discrepancies in documentation between surgeons which the department is hoping to streamline to avoid any gaps that could have patient care, legal or cost implications in the future.