Medicolegal Purposes Research Articles

WP4.9 - Audit on writing outpatient clinic letters in the general surgery department at a tertiary care hospital

Abstract Background Clinic letters are crucial medical notes for a patient’s medical history and medico-legal purposes. We assessed the quality of clinic letters with the guidelines from the Academy of Medical Royal College suggested for writing a clinic letter. Method A retrospective collection of data was done from January – May 2023 and a total of 166 clinic letters were collected by independent authors and then analysed to avoid any bias in the collection. Results Multiple parameters were poorly documented and are mentioned in increasing order of missing data – Plan for patient/carer (37.5%), Care planning arrangements (44.6%), Complications (67.5%), Anaesthesia issues (89.4%), Allergies (94%), Diagnosis (94%), Time (99.4%), Preferred name (100%) and Personal identifiers (100%). These findings were presented in the clinical governance meeting and to improve the quality of the clinic letters, we created a generic clinic letter including mandatory parameters suggested by the guidelines. Conclusion There were a few parameters missing from the analysed clinic letters. An adequate intervention after being discussed in the clinical governance meeting, in the form of a generic clinic letter has been introduced. A repeat cycle is planned in 3-5 months to assess the improvement in the quality. There was a lack of documentation, which improved after the intervention advised by QIP. A teaching session for new junior doctors is planned at the induction session, to strengthen the importance of frailty documentation.

ESTIMATION OF CANINE DIMENSIONS AS PREDICTORS OF SEX IN THE SOUTHERN BULGARIAN POPULATION

Purpose. Sex determination in forensic anthropology is an essential step for medicolegal purposes and very important for identification, as the number of possible matches will be halved. A dental profile includes all the individual dental traits and dimensions which can provide significant information on such human biological problems as the genetic relationships between populations and human environmental adaptation. The purpose of this research was to determine the sex differences in dental measurements of canines, inter-canine width, and canine indices in Bulgarians. Material and Methods. The study included 169 subjects of Bulgarian origin in the age group of 20 – 40 years. Buccolingual, mesio-distal and cervicoincisal diameters of canines and inter-canine width were measured by Dentistry Sliding Vernier Caliper and analyzed with SPSS 28.0. Maxillary and mandibular canine indices were calculated. Results. Mesio-distal and cervicoincisal dimensions of upper canines, inter-canine width and mandibular canine index exhibited statistically significant differences with a high degree of significance between males and females in contrast with the maxillary canine index of Bulgarian males and females, which revealed no statistically significant differences. Conclusion. In accordance with similar odontometric studies, canines, inter-canine width, and mandibular canine index may differentiate both sexes successfully, and thus they can be reliable predictors in forensic identification.

Assessment and diagnosis of post-traumatic stress disorders (PTSDs) for medico-legal and other clinical purposes: DSM-5-TR PTSD, ICD-11 PTSD and ICD-11 complex PTSD

SUMMARY Post-traumatic stress disorder (PTSD) is a complex, heterogeneous mental health problem that can be challenging to identify, assess, understand, diagnose and treat. This article provides an overview and critique of key topics, literature and principles to inform comprehensive and meticulous assessment of PTSDs. Although expert witnesses are the target audience, this article will have relevance for identifying, assessing, understanding and diagnosing PTSDs in all clinical contexts. A range of topics relevant to assessment are discussed, including: the complex relationship between trauma and PTSDs; DSM-5-TR PTSD and ICD-11 PTSD and complex PTSD diagnoses and the similarities and differences between them; the clinical presentation of PTSDs; psychological models of PTSDs; how to approach assessment and differential diagnosis; the impact of PTSD on neuropsychological abilities and functioning (disability); causation, reliability and assessing PTSDs when this is being considered as a legal defence; evidence-based interventions (medication, psychological therapy, when is the ‘right time’ for therapy, contraindications); and prognosis (if untreated, how long therapy/change takes). Given ongoing debate, the article proposes that trauma exposure is best defined in future iterations of the DSM and ICD as exposure to one or more psychologically threatening or horrific experiences that are overwhelming.

Correlation of cardiotocography with combined APGAR scores and diagnostic performance of umbilical cord parameters in predicting low combined APGAR scores – A prospective Cohort study

ObjectivesCombined Apgar score includes utilization of interventions such as Continuous positive airway pressure, Oxygen, Mask and Bag ventilation, I ntubation and ventilation, Ne onatal chest compression, Drugs, and newborn assessment. It has been proposed as a substitute for conventional Apgar score which is the gold standard for evaluating newborns right after birth but is impacted by medical interventions and preterm. Combined Apgar scores were examined to check for correlation with CTG tracing and umbilical cord blood parameters which gives an objective assessment of fetal hypoxia, in response to the demand for a more accurate tool for evaluating the neonate and to be used for medico-legal purposes. The study's objectives were to (1) determine the association of combined Apgar scores with suspicious and pathological CTG (2) the association of umbilical cord parameters with low combined Apgar scores and the diagnostic performance of these parameters in predicting low combined Apgar scores. Study designA prospective observational cohort study was conducted in a tertiary care center in East India. 2350 consecutive laboring mothers who had completed 34 weeks of gestation underwent cardiotocography according to institutional protocol and those with suspicious and pathological CTG who delivered within 1 h of abnormal CTG were recruited. Arterial blood was analyzed and the newborn was evaluated immediately after delivery with a combined Apgar scoring system ResultsOf the 2350 women, 50.7 % and 49.3 %, respectively, exhibited suspicious and abnormal CTG tracings. CTG was reported to have low diagnostic accuracy and specificity, with a sensitivity of 66.7 % and 88.9 %, respectively, in detecting combined Apgar at 1 and 5 min. The combined Apgar score at five minutes showed a strong association with acidosis. There was a statistically significant correlation between low combined Apgar and excess lactate and base at one and five minutes. With 100 % sensitivity and 95 % specificity, high lactate levels > 4.1 mM/L were found to predict newborn encephalopathy. ConclusionUmbilical cord blood parameters were found to be correlated with low combined Apgar scores. Combined Apgar scores may be a more useful tool for neonatal assessment and long-term morbidity of newborns. Additional research is required to determine whether it can take the role of conventional Apgar scores in clinical practice.

Dental Age Assessment Based on Developmental Stages and Maturity Index of Third Molars for Medico-Legal Purposes.

As results may vary depending on the method of examination, this paper analyzes methods of age estimation based on the maturation index of third molars (I3M) and Kohler's developmental stages in living individuals. A total of 1475 orthopantomograms were analyzed. The results showed that the development of third molars tended to be more advanced in males than in females. Regression equations that included the value of the developmental stage of the left third molar most accurately predicted chronologic age in males and females. Using the I3M method, there were no statistically significant bilateral differences between the mandibular right and left third molars. Overall, 82.92% of males and only 72.82% of females were correctly classified with the cut-off value (0.08) for the left mandibular third molar index. In addition, 81.97% of individuals were correctly classified as minors and adults using the Kohler method, while only 78.62% of individuals were correctly classified as minors and adults using the I3M method. Based on the misclassification of minors as adults, both methods should be used with caution and overestimation of age should be considered, especially for those close to 18 years of age.

A Comprehensive Review of a particular Skin Injury: Pathogenesis, triggers, and current Treatment Options

By definition, an open injury is any severe break in the continuity of the skin and deep tissue. Because contusions are healed injuries, the term given above does not apply to them. The classification of injuries is essential for both therapeutic and medico-legal purposes. Burn injuries are comparable to other injuries in that they require the same basic principles for healing and care, but they differ in that they have a greater impact on the patient's overall health and are essential to the patient's eventual survival, the development of deformity, and rehabilitation. Treatment of burn injuries has always been the responsibility of burn specialists. Both local and systemic therapy have long been advised for treating burn injuries and minimizing burn scars. This review summarizes the treatment of burn injuries brought on by a variety of physical and chemical agents requires unique regimens that are completely different from those used to treat any other traumatic injuries. Other acute injuries that undergo entire blood loss result in shock, but major burns that experience significant plasma loss due to increased capillary permeability result in distress. Burn injuries are initially sterile compared to the majority of other injuries, however, due to the immunocompromised state of burn patients and injury infection frequently ends in death in serious burns. We have discussed the pathophysiology, primary care therapies, nanomaterials used in injury healing therapy and various nanoparticles in injury healing process for burn injuries in this review.

The Role of Fingernails in Death Investigation.

In forensic pathology, forensic onychology studies fingernails and toenails for medicolegal purposes. It mainly deals with DNA profiling from nails, toxicological analysis for detecting poisons, and the collection of trace evidence present under the nails. Injuries to fingernails and their interpretation for medicolegal purposes are the neglected areas of this study. We have discussed the most common types of fingernail injuries and their significance. We found that their notification has significant value in drowning cases, defense wounds on the palm, self-inflicted cuts, burns, electrocution, blunt trauma, physical assault, sexual offenses, and other issues like torture. We emphasize the examination of fingernails in the autopsy and medicolegal clinical examination for better administration of law and justice.

The role of ultra-widefield imaging with navigated central and peripheral cross-sectional and three-dimensional swept source optical coherence tomography in ophthalmology: Clinical applications.

To assess central and peripheral retinal and choroidal diseases using ultra-widefield (UWF) fundus imaging in combination with navigated central and peripheral cross-sectional and three-dimensional (3D) swept source optical coherence tomography (SS-OCT) scans. Retrospective study involving 332 consecutive patients, with a nearly equal distribution of males and females. The mean age of patients was 52 years (range 18-92 years). Average refractive error was -3.80 D (range +7.75 to -20.75 D). The observations in this study demonstrate the efficacy of peripheral navigated SS-OCT in assessing various ocular conditions. The technology provides high-quality images of the peripheral vitreous, vitreoretinal interface, retina, and choroid, enabling visualization of vitreous floaters and opacities, retinal holes and tears, pigmented lesions, and peripheral retinal degenerations. 3D OCT scans enhance the visualization of these abnormalities and improve diagnostic and therapeutic decisions. Navigated central and peripheral cross-sectional and 3D SS-OCT scans offer significant complementary benefits in the assessment and management of retinal diseases. Their addition to UWF imaging provides a comprehensive view of central and peripheral ocular structures, aiding in early detection, precise anatomical measurements, and objective monitoring of disease progression. In addition, this technology serves as a valuable tool for patient education, a teaching tool for trainees, and documentation for medico-legal purposes.

Demystifying the Radiography of Age Estimation in Criminal Jurisprudence: A Pictorial Review.

Skeletal radiographs along with dental examination are frequently used for age estimation in medicolegal cases where documentary evidence pertaining to age is not available. Wrist and hand radiographs are the most common skeletal radiograph considered for age estimation. Other parts imaged are elbow, shoulder, knee, and hip according to suspected age categories. Age estimation by wrist radiographs is usually done by the Tanner-Whitehouse method where the maturity level of each bone is categorized into stages and a final total score is calculated that is then transformed into the bone age. Careful assessment and interpretation at multiple joints are needed to minimize the error and categorize into age-group. In this article, we aimed to summarize a suitable radiographic examination and interpretation for bone age estimation in living children, adolescents, young adults, and adults for medicolegal purposes.

EGS P38 Audit of operative notes/ Clinical documentation of emergency laparotomy & laparoscopic bowel resection procedures

Abstract Background Laparotomies and laparoscopic bowel resections are common emergency procedures carried out in General Surgery emergency theatres. Get It Right First Time (GIRFT), Royal College of Surgeons (RCS) and The Association of Surgeons of Great Britain and Ireland (ASGBI) have made best practice recommendations for documenting operative notes, to ensure effective communication with colleagues and for medicolegal purposes. Ensuing medicolegal issues and patient complaints have cost departments in recent times, due to poor documentation. This audit within a busy General surgery unit, assesses the quality of operative documentations against the standards set by GIRFT, RCS and ASGBI. Methods A retrospective audit of operative notes and relevant clinical documentation of 100 emergency laparotomies and laparoscopic bowel resections between August 2022 and March 2023 at a local General surgery unit. Patient Identification Numbers were extracted from the National Emergency Laparotomy Audit (NELA) database. Operative records and clinical documentations were obtained from electronic clinical records. The recommendations from the “GIRFT RCS and ASGBI Best Practice for Laparotomy and Laparoscopic Bowel Resection Surgery Documentation” guidance was used as the Standard. Up to 60 variables were assessed across different stages of the patient journey, from preoperative to intraoperative and postoperative stages. Results In the period reviewed, there was varying performance. Good performance in documentations of Indications, Operator names, patient position, incision, and findings, seen in 99, 100, 100, 100 and 100 percent of cases respectively. Anaesthetist name was documented in 48% of cases, whilst WHO checklist was documented in only 20% of cases. 64 of these cases had bowel resections. In this cohort, methods and location of resection was described in 95% of cases. Only 43% had the state of bowel prefusion at transection site documented. VTE prophylaxis, Antibiotics, sutures/clip plan, were documented in 87, 65 and 13 % of cases respectively. Conclusions The audit highlights deficits in important areas of documentation, despite the set guideline. Important medicolegal issues can arise when documentations are not clear, and steps considered routine as not written in the operative notes or patient’s records. The findings will be disseminated, and recommendations will be suggested across all grades of surgeons, with the aim to re-audit and improve quality of documentation and ultimately improve delivery of surgical care. A plan to have electronic documentation template or checklist for these procedures has been carried out for trial with the aim of developing standardised documentation process.

A Clinical Audit of Orthopaedic Clinical Documentation of Acute Ankle Fractures: A Quality Improvement Project.

Background Orthopaedic ankle fractures are common injuries that require careful assessment, management, and documentation to ensure optimal patient outcomes. Proper documentation plays a critical role in facilitating communication among healthcare professionals, ensuring accurate diagnosis, treatment planning, and monitoring patient progress. Moreover, it is essential for medico-legal purposes and quality improvement initiatives. This article presents a comprehensive clinical audit aimed at evaluating the quality of orthopaedic ankle fracture documentation within a healthcare setting. The aim of this project was to assess the quality and accuracy of ankle fracture documentation within a single centreagainst the audit standards set by the British Orthopaedic Association (BOA) and the National Institute for Health and Care Excellence (NICE). Methods The study was a closed-loop audit utilising both retrospective and prospective analysis of ankle fracture clerking documentation performed by members of the trauma and orthopaedics team. Two audit cycles were completed in total; the first cycle was carried out in January 2020 where data were collected retrospectively from all orthopaedic admissions of ankle fractures. This was then re-audited against the BOA and NICE guidelines and presented to the local clinical governance meeting. A targeted educational intervention was then implemented with the goal of educating and reinforcing to key team members the documentation standards and the importance of accurate clerking documentation. The second cycle was carried out during July 2020 prospectively. All data were collected and collated with a total of nine data parameters analysed. Patients were included if they were skeletally mature and presented with closed malleolar and syndesmotic ankle injuries. Excluded patients were those who presented with open fractures, pilon fractures, and/or were skeletally immature. Data were then re-presented at the clinical governance meeting. Results A total of 23 patients were identified in the initial audit cycle and 22 patients in re-audit. On admission, it was found that 86% of patients presenting with ankle fractures had adequate documentation of their injury mechanism, which subsequently improved to 100% following the intervention. Similarly, there was a 71% improvement in precise documentation of clinical findings of ankle fractures. There was a marked improvement in the consistency of examination findings as well, with over 30% improvement in the rate of documentation for sensation status, skin integrity, circulation, and motor function. Results also revealed a 71% improvement in the documentation rates of vascular examinations where a Doppler ultrasound was used or pulses named in the documentation. Conclusion Through a targeted educational scheme focussing on the proposed documentation guidelines, we noted a significant improvement in documentation standards and accuracy of ankle fractures in the trauma and orthopaedic department. With ongoing educational input and reinforcement, team members can be supported to maintain a high level of documentation that meets all available standards, which will ultimately lead to improved patient care.

What is important to the GP in recognizing acute appendicitis in children: a delphi study

BackgroundFor diagnostic research on appendicitis in registration data, insight is needed in the way GPs generate medical records. We aimed to reach a consensus on the features that GPs consider important in the consultation and medical records when evaluating a child with suspected appendicitis.MethodsWe performed a three-round Delphi study among Dutch GPs selected by purposive sampling. An initial feature list was created based on a literature search and features in the relevant Dutch guideline. Finally, using a vignette describing a child who needed later reassessment, we asked participants to complete an online questionnaire about which consultation features should be addressed and recorded.ResultsA literature review and Dutch guideline yielded 95 consultation features. All three rounds were completed by 22 GPs, with the final consensus list containing 26 symptoms, 29 physical assessments and signs, 2 additional tests, and 8 further actions (including safety-netting, i.e., informing the patient about when to contact the GP again). Of these, participants reached consensus that 37 should be actively addressed and that 20 need to be recorded if findings are negative.ConclusionsGPs agreed that negative findings do not need to be recorded for most features and that records should include the prognostic and safety-netting advice given. The results have implications in three main domains: for research, that negative findings are likely to be missing; for medicolegal purposes, that documentation cannot be expected to be complete; and for clinical practice, that safety-netting advice should be given and documented.

A rare cases of ferrous sulphate poisoning- A case study

A poison is a substance which when administrated, inhaled or ingested is capable of causing deleterious effect on the human body. The circumstances may be suicidal, homicidal or accidental. A suicidal poison of choice must be cheap, easily available and capable of being administered is any food or drink. It must have pleasant taste and no repulsive smell. The action of poison may be local, remote, combined and general. The preparations of iron salt, which are largely used in medicine are mostly prepared from sulphate, carbonate and perchloride of iron. When these salt are administered in large doses, they produce poisonous symptoms and may even cause hemosiderosis as a manifestation of chronic poisoning. Iron sulphate (ferrous Sulphate, FeSo4) is commercially known as green vitriol of sulphate. It forms green, efflorescence monosymmetric crystals on exposure to the atmosphere. It is freely soluble in water. It is used in making blue ink and dyes, but sometimes as a pesticide. In this case study, we'll talk about a woman who died after consuming an corrosive drug at home. For medico-legal purposes, it was critical to correlate autopsy results with medical care records and the place of the incident.

1129 LaCON: A Quality Improvement Project on Laparoscopic Cholecystectomy Operation Notes

Abstract Aim Accurate and comprehensive operation notes are crucial for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy (LC) is one of the most common procedures in General Surgery, either in an Elective or Emergency setting. Therefore, there is a need for an accurate and standard way to document the operation notes for a safe immediate and late post-operative care, including follow-up. The LaCON project aims to evaluate and improve the quality of the operation notes. Method A retrospective review of operation notes of LCs performed at our institution between August-November 2022. Electronic notes were assessed against the Royal College of Surgeons’ Good Surgical Practice standard, consisting of 18 items. Results A total of 80 operation notes were reviewed. There was 100% compliance in surgeon’s name, operation procedure, incision, port sites, and closure technique. Other high-scoring items were 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%), operative diagnosis (16%) and estimated blood loss (EBL) (8%). Conclusions We identified several areas for improvement in LC operation notes, such as a detailed and robust post-operative plan, a precise intraoperative diagnosis and information about EBL. The LaCON project highlighted the need to implement an electronic evidence-based proforma to standardise notes. This proforma will be accessible through a secure online app, in line with the local Hospital policies, and will allow accurate and contemporaneous record keeping and efficient extraction of operative data for analysis.

678 The Safe Use of Intraoperative Tourniquets in Orthopaedic Procedures

Abstract Aim The use of intra-operative tourniquets in orthopaedic procedures is required to provide bloodless fields, enabling surgical procedures to be performed with improved quality, accuracy, and safety. Documentation of tourniquet use is necessary for optimising patient safety, as this provides an essential medico-legal role, as well as ensures the continuity of care for patients. Method All patients who had orthopaedic procedures in the local hospital in November 2022 were reviewed. There were a total of 123 procedures. 40 procedures required intra-operative tourniquet use were included in our study. The primary outcome is the documentation of tourniquet use, which includes the site of the tourniquet applied, the pressure, and the duration of tourniquet use. The secondary outcome is compliance with tourniquet use according to the national guidelines set by BOA Standards for Trauma and Orthopaedics (BOAST). This states the maximum authorized pressure, depending on the age (below/above 16), and the type of procedures (upper/lower limb). Results All procedures (N = 40) recorded the site of the tourniquet attached. 68% (27/40) of procedures recorded the length of the tourniquet use and 63%(25/40) recorded the maximum pressure applied. From the recorded procedures, the length of tourniquet use (N = 27) and maximum pressure applied (N = 25) is compliant with the national BOAST guideline regardless of the age group and type of procedures. Conclusions Overall this study highlighted the importance of documentation of tourniquet use for medico-legal purposes while demonstrating high compliance with the BOAST guidelines. This could ultimately overcome the challenges associated with intra-operative complications, thus optimising patient safety.

901 Assessing Adherence to RCSEng Standards for Operation Notes in Patients With Neck of Femur Fractures: A Closed Loop Audit

Abstract Aim To determine the accuracy with which Royal College of Surgeons of England (RCSEng) standards for documenting surgical procedures were met within a defined patient group, with the goal of improving patient safety, and improving documentation for medicolegal purposes. Method We conducted a closed loop audit on adherence to RCSEng standards for operation notes. We calculated the percentage adherence for each measurable standard and overall note, and presented the data at a local clinical governance meeting. We implemented autotext templates for operations to improve quality of operation notes in following RCSEng standards. We collected data retrospectively after 3 months to complete the audit cycle. Results We included 24 patients in the first cycle and 16 patients in the second cycle. Prior to intervention, the overall percentage of measurable standards met was 69.4%, which increased to 76.4% after intervention. The five least adherent standards all improved in percentage, with the largest increase from 33.3% to 93.8%. Conclusions In the first cycle, 3 of the measurable standards were met 100% of the time, which increased to 4 in the second cycle. Along with the general improvement of standards met, the interventions improved patient safety and surgeon documentation. Operation notes using templates generally recorded higher percentages of standards met than those without templates, but further work is needed to ensure more standards meet the 100% ideal.

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

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.

232 The inGuinal heRnia OperatIon Notes (GROIN) Quality Improvement Project

Abstract Aims Accurate and comprehensive operation notes are crucial for patient safety, quality assurance and medico-legal purposes. Inguinal hernia repair is one of the most common surgical procedures. Thus, operative documentation should be precise and standardised. The GROIN project aims to improve the quality of inguinal hernia operation notes using evidence-based proformas and an operation note composition software. Method We retrospectively reviewed operation notes of inguinal hernia repair performed at our institution between August and November 2022. Operation notes were assessed against the Royal College of Surgeons' Good Surgical Practice standard, consisting of 18 items. Results The operation notes from 89 cases were reviewed. High-scoring items included: operation name (100%), operative findings (99%), surgeon's name (99%), closure technique (98%), operation date (90%) and signature (90%). Postoperative instructions were sufficiently detailed in 79% of cases. Regarding mesh placement, 63% of notes described mesh size and type, whereas 30% documented only the mesh type. The lowest-scoring items were: venous thromboembolism prophylaxis (31%), designation as elective or emergency (22%), operative diagnosis (6%), and estimated blood loss (2%). Conclusions We identified several areas for improvement in inguinal hernia operation notes based on our results. The next step of the GROIN project is to standardise operation note creation by implementing an evidence-based template, which will be delivered through a novel operation note composition software. This will allow accurate record-keeping and efficient operative data extraction analysis. Efforts to standardise operative notes and enhance their quality on a national and international level are imperative for patient safety.

WTP6.7 Implementation of a Trust-wide electronic operation note proforma – a quality improvement project

Abstract Aims The operation note is an important document that records intra-operative details and provides post-operative instructions. It ensures continuity of care and may be used for medicolegal purposes. In our Trust, there is a move towards electronic operation notes in line with the digitisation of patient records. Here we report initial data from our multi-staged implementation of a Trust-wide electronic operation note proforma. Method The Plan/Do/Study/Act (PDSA) method was used. Regular key stakeholder meetings were held involving the Information Technology (IT) department and various surgical teams. The Royal College of Surgeons’ Good Surgical Practice (GSP) provided minimum standards for operation notes. Forms4Health was used as the platform for electronic operation notes. In PDSA cycle 1, a retrospective audit was performed involving 50 randomly selected handwritten or typed operation notes. The operation notes were audited by two independent reviewers against GSP standards. Handwritten operation notes were also assessed for legibility. Results A total of 29 handwritten and 21 typed operation notes were analysed. Among the handwritten operation notes, 15 (52%) were legible. Handwritten notes demonstrated 68% compliance with GSP standards, as compared to 79% for typed notes (p <0.05). Typed notes were superior at recording time of surgery (p <0.01), whether it was elective or emergency (p <0.01), complications encountered (p <0.05) and thromboprophylaxis instructions (p <0.01). Conclusions Our data indicate a significant improvement in GSP compliance via electronic notes. As next steps, we will integrate the proforma into existing Trust IT platforms and include additional features to increase user efficiency and re-audit service improvement.

Anthropometric study of facial and nasal indices of the Akan ethnic population of Ghana

Introduction: Facial anthropometry is required in many medical and dental disciplines, particularly for prosthodontists, orthodontists, plastic surgeons, maxillofacial surgeons, and forensic medicine experts. An individual's facial shape is a reflection of their race, age, and gender. The present study aimed at determining the facial and nasal indices among the Akan ethnic group in Kumasi, Ghana.Methodology: A total of 307 (182 males and 125 females) Akan adult volunteers between the age of 18 - 30 years were recruited for the study. Standard procedures were used to obtain the necessary facial and nasal measurements for generating the appropriate indices. A p-value of 0.05 or less was judged statistically significant.Results: In males, the facial index ranged from 75.28 to 117.90, while in females it ranged from 76.58 to 97.87. The nasal index ranged from 52.0 to 115.3 in males and 52.0 to 105.7 in females. There were significant differences between males and females in all facial parameters utilized to calculate facial and nasal indices. The facial index, but not the nasal index, differed significantly between Akan males and females. Mesoprosopic was the most prevalent face type in both male and female Akan populations, whereas mesorrhine was the most common nose type.Conclusion: The findings of this study can be used as a reference to improve the outcome of cosmetic and reconstructive facial surgery and rhinoplasty, as well as for medico-legal purposes in the Akan people of Ghana.