Operative Note Proforma Research Articles

Improving the Quality and Standardization of Operative Notes in a Tertiary Regional ENT Department: A Closed-Loop Audit.

Comprehensive and accurate documentation is paramount in ensuring patient safety, and continuity of care, and casts the foundation for auditing practice and creating research. Unfortunately, a lack of documentation has been reported globally. This study aims to challenge current practices and ensure high-quality documentation. The study appraised 100 operation notes completed within a tertiary, regional ENT department against the published guidance. Following an inquiry into the findings, the operative note proformas were modified in alignment with the Royal College of Surgeons (RCS) published standards for the quality of operative notes. A further 100 operation notes were audited. Rates of compliance before and post implementing the intervention were compared. Non-parametric data were analyzed using Fischer's exact test, with P< 0.05 considered to be statistically significant. Upon auditing of operative note completeness against the set criteria, the use of a comprehensive operative note proforma significantly refined the quality of documentation and adherence to the published standards (P< 0.00001). This study displayed the lack of adherence to the RCS standards about the quality of operative notes within our center. The adoption of a modified proforma which incorporates the 18 criteria defined by the RCS resulted in improved conformance to published standards and a higher quality of documentation. This study corroborates the RCS framework as an effective tool in recognizing deficient practices and areas of improvement. Through compliance with published standards, a higher quality of documentation is attained, contributing to patient safety, clear continued communication, and support of clinical governance.

Development of a New Knee Arthroscopy Operative Proforma Saving Thousands of British Pounds.

Coding inaccuracies in documentation of surgical procedures misrepresent the productivity of departments, with harmful fiscal consequences and detract from effective clinical governance. We aimed to assess the extent of this within our centres. We retrospectively analysed the operative records of 34 patients from two centres over a period of a month, undergoing varying arthroscopic knee operations. We found that 50% of cases had incorrect coding for procedures performed. On review of the clinical coding, the loss of payment summed up to £29,325. The flawed coding practices stemmed from the heterogeneity and convolution in documentation of procedures. Our intervention was the development of a multi-faceted arthroscopic operation note proforma, centred on concise documentation for appropriate codes to be gleaned. We re-audited our new proforma, retrospectively collating data on 37 patients over a period of five months undergoing arthroscopic knee procedures. We found only 5% of cases were coded incorrectly, summing to a loss in tariff payment of £2654. In conclusion, poor quality of documentation and written communication between surgical and coding departments can have drastic ramifications for funding. An active refinement of this process can ultimately help to provide more resources for improved patient care.

1083 Evaluating Adherence to Best Practice for Tissue Sampling in Diabetic Foot Surgery: A Quality-Improvement Study

Abstract Aim To evaluate adherence to national guidelines (National Institute for Health and Care Excellence – NICE) in tissue sampling during diabetic foot surgery, and to assess the clinical course of minor diabetic foot amputations in relation to bone microbiology and antibiotic therapy. Method Between 2020 and 2022, three separate cycles of a plan-do-study-act (PSDA) audit were completed to evaluate the efficacy of a teaching programme and an online operation note proforma. Data were collected retrospectively with the primary outcome measures being the proportion of clinically clean bone samples sent and subsequent impact on changes to targeted antibiotic therapy. Secondary outcomes included the rates of re-infection and re-intervention. Results A total of 106 patients were sampled (PDSA 1, n = 52; PDSA 2, n = 27; PDSA 3, n = 27). Following the implementation of a departmental teaching programme the proportion of clinically clean bone samples increased from 68% (PDSA 1, n = 40) to 75% (PDSA 2, n = 12) with a further increase to 89% (PDSA 3, n = 24) after implementation of the online proforma (p = 0.140). Microbiology results prompted necessary changes to targeted antibiotic therapy in 58% of patients (PDSA 1, n = 33) increasing to 95% throughout the study (PDSA 3, n = 19). Targeted antibiotic therapy was associated with comparable rates of re-infection compared to non-targeted therapy (PDSA 3, 5% / 12.5%, respectively) but overall lower rates of re-intervention (PDSA 3, 63% / 47%, respectively). Conclusions Both interventions were associated with increased rates of clinically clean intra-operative bone sampling. Lower rates of re-intervention were observed in patients who subsequently received targeted antibiotic therapy.

1186 Cholecystectomy Operation Notes - a Review and Core Trainee Survey

Abstract Aim The “Good Surgical Practice” document by Royal College of Surgeons (RCS) England, in line with GMC’s “Good Medical Practice” emphasises the importance of “clear operative notes for every procedure”. The importance of clear documentation is well-established, facilitates effective handover and represents a legal document. A study was conducted to assess current documentation standards, including a survey amongst core surgical trainees on the use of a proforma for documenting cholecystectomies. Method A retrospective review of cholecystectomy operation notes collected from hospital database was performed between February 2022 and July 2022. Operative documentation was compared to the guideline published by RCS England. Specific information relevant to cholecystectomy operation were reviewed; critical view of safety/Calot’s triangle, number and type of clips, gallbladder dissection difficulty and spillage of bile/stones. Compliance to RCS standards was considered satisfactory at ≥80%. Results 109 typed operation notes were reviewed. Majority of information including date and time (100%), procedure name (99%), name of surgeon and assistant (100%), operative findings (100%) and post-operative care instructions including VTE prophylaxis (92%) were clearly documented. Shortfalls in documentation included priority of operation (63%), intraoperative complications (66%), gallbladder dissection difficulty (53%), anaesthetist name (52%), removal of ports under vision (33%) and local anaesthetic details (70%). Survey of eight core surgical trainees found a consensus that a proforma would improve understanding and documentation of the procedure. Conclusions The use of an operation note proforma in cholecystectomies could improve patient care and compliance with RCS guideline, and act as a learning modality for surgical trainees.

131 Cholecystectomy operation notes - a review and core trainee survey

Abstract Aim The “Good Surgical Practice” document by Royal College of Surgeons (RCS) England, in line with GMC’s “Good Medical Practice” emphasises the importance of “clear operative notes for every procedure”. The importance of clear documentation is well-established, facilitates effective handover and represents a legal document. A study was conducted to assess current documentation standards, including a survey amongst core surgical trainees on the use of a proforma for documenting cholecystectomies. Methods A retrospective review of cholecystectomy operation notes collected from hospital database was performed between February 2022 and July 2022. Operative documentation was compared to the guideline published by RCS England. Specific information relevant to cholecystectomy operation were reviewed; critical view of safety/Calot’s triangle, number and type of clips, gallbladder dissection difficulty and spillage of bile/stones. Compliance to RCS standards was considered satisfactory at ≥80%. Results 109 typed operation notes were reviewed. Majority of information including date and time (100%), procedure name (99%), name of surgeon and assistant (100%), operative findings (100%) and post-operative care instructions including VTE prophylaxis (92%) were clearly documented. Shortfalls in documentation included priority of operation (63%), intraoperative complications (66%), gallbladder dissection difficulty (53%), anaesthetist name (52%), removal of ports under vision (33%) and local anaesthetic details (70%). Survey of eight core surgical trainees found a consensus that a proforma would improve understanding and documentation of the procedure. Conclusion The use of an operation note proforma in cholecystectomies could improve patient care and compliance with RCS guideline, and act as a learning modality for surgical trainees.

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 &amp;lt;0.05). Typed notes were superior at recording time of surgery (p &amp;lt;0.01), whether it was elective or emergency (p &amp;lt;0.01), complications encountered (p &amp;lt;0.05) and thromboprophylaxis instructions (p &amp;lt;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.

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

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.

An electronic operation note proforma improves the quality of operation notes in burns surgery.

An Operation Note should provide a comprehensive account of the details of a surgical procedure performed and document clinically relevant events which occur throughout the procedure. The Royal College of Surgeons of England, in 2014, updated guidelines on specific criteria to be included in operation notes. Standardisation using procedure-specific operation notes has been shown to significantly improve adherence to these guidelines. The aim of this study was to evaluate the quality of operation notes in the Irish National Burns Unit before and after the design and implementation of an electronic patient record and the subsequent introduction of an operation template and a burns surgery specific checklist, within the electronic system. A 30-point checklist was designed based on existing sources. Operation notes prior to and following the adoption of a electronic-based operation note were analysed, and then reanalysed following the introduction of a procedure-specific operation note. Ninety-three operation notes were included for analysis. An electronic operation record significantly improved the quality of documentation within our unit. The subsequent procedure specific operation note had a significant improvement across all areas and achieved 100% compliance in many categories. The use of an electronic patient record to document a patient's procedure has been shown to significantly improve the quality of documentation. One could expect this to result in an improved patient hand-over and subsequent episode of care. We highlight a number of initial pit-falls that others may avoid in their implementation of a digital record.

579 The Perfect OP Note - in the World of Surgery - QIP/Clinical Audit

Abstract Aim To audit by assessing the completeness of the operative note and if it follows the guidelines and the standard recommendations mentioned in the RCS &amp; BMJ articles. Method The audit was registered with the clinical audit department prior to data collection and analysis of the results, Inpatient scanned records were analysed for all operative notes, From 1st June 2020 to 15 June 2020 - From 14th Feb 2021 to 21st Feb 2021 &amp; 1st March 2021 to 7th March 2021 - All trauma and orthopaedic patients were included regardless of the type of procedure. There were no exclusion criteria in place, All operative notes were analysed &amp; scored against 34 operative criteria's according to ‘good surgical practice’ &amp; BMJ article’ Results These 96 operative notes were analysed against 34 unique criteria which were gathered from a combination of RCS guidance criteria for operative notes and different trusts operative note proforma headings There was an increase of 40% in typed operative notes that increased the compliance with the 34 unique criteria. Improvement was seen in 11 unique criteria after the 3rd PDSA cycle. Conclusion Facilitation of generic templates, and findings of the Audit itself and then the presentation - brought about a positive change - with more detailed operative notes and improved the quality of the documentation.

AB104. SOH22ABS156. Is there a role for an operative note proforma for common on call surgical procedures?—A clinical audit assessing the quality of operative notes in incision and drainage of pilonidal abscesses

AB104. SOH22ABS156. Is there a role for an operative note proforma for common on call surgical procedures?—A clinical audit assessing the quality of operative notes in incision and drainage of pilonidal abscesses

374 Are Operative Notes Adhering to the Standards of Good Practice?

Abstract Aim Thorough documentation is imperative for postoperative care, quality improvement, research, and medico-legal enquiries. For these reasons this closed loop audit aimed to assess whether the local Trauma and Orthopaedic departments’ operative notes were adhering to the guidance outlined by The Royal College of Surgeons, in order to to follow good practice. Method This was a random data collection, single centre study performed which analysed 50 operative notes from a variety of Trauma and Orthopaedic surgical procedures (not including neck of femur fractures and elective surgeries). The next cycle of the audit was completed after departmental re-education and a new operative note pro forma was created and put in place. Results The first audit cycle demonstrated that 8 categories in the operative note were below 96 % compliance with the guidance, of these being: time, name of operating surgeon/anaesthetist, operative procedure, incision, operative diagnosis, DVT prophylaxis, signature. Furthermore, an interesting finding showed no complications were identified in any operative note, similarly no extra procedures were documented. The second audit cycle showed that there was 100% compliance gained across all categories. Additionally, the new pro forma had an option to specify if there was/or not any complications, which had 100 % compliance in the second cycle and identified one complication. Conclusions Overall this audit was able to standardise the operative notes and improve quality and structure in order to follow good practice, by implementing a new pro forma and re-educating the department. This ensures that the best standard of care is being delivered.

684 The Standard of Emergency Operation Note Documentation at A District General Hospital Compared Against The Royal College of Surgeons of England (RCSEng) Standard

Abstract Introduction Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma. Method A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020. Results RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p &amp;lt; 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p &amp;lt; 0.0001), estimated blood loss (2% vs 63%; p &amp;lt; 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p &amp;lt; 0.0001). Conclusions Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.

An audit to identify adherence of laparoscopic appendicectomy operation notes to Royal College of Surgeons Good Surgical Practice standards

Appendicitis is the most common abdominal emergency in England accounting for 40,000 admissions per year. The Good Surgical Practice guideline by Royal College of Surgeons England (RCSEng) defines criteria detailing what constitutes a safe and comprehensive operation note. High-quality operation notes enable continuity of care and safe post-operative management. (1) Assess whether laparoscopic appendicectomy operation notes are adherent to RCSEng criteria. (2) Implement an operation note proforma to improve adherence. (3) Re-audit to assess effectiveness of operation note proforma. A retrospective audit was performed measuring compliance of laparoscopic appendicectomy notes to RCSEng criteria over a 4-month period at a central London tertiary care centre. A laparoscopic appendicectomy operation note proforma was designed and implemented. Compliance to RCSEng criteria was then re-audited against RCSEng criteria, and statistical analysis performed to assess the significance of changes to compliance. The average compliance with the RCSEng guidelines after the first cycle retrospectively was 56.1%. The average compliance after implementation of the proforma was 98.2%, with above 80% of operation notes satisfying all RSCEng criteria. This was a significant 42.1% (p<0.0001) increase in average compliance. The implementation of the proforma reduced the amount of hand-written information, saving time and improving legibility of the operation notes. The implementation of an operation note proforma has the ability to significantly improve operation note quality. This simple and effective intervention to improve operation note quality has the potential to improve post-operative safety and continuity of care post laparoscopic appendicectomy.

Improving the quality of operation notes: Effect of using proforma, audit and education sessions

Both from a medical and legal point of view, the quality of operative notes are important. In this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re-audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. The results of each audit were compared. In the first audit, it was found that fourteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), patient position (1.3%), and amount of bleeding (0%). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters. This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. The use of proforma provides much better results.

Improving the quality of operative notes for laparoscopic cholecystectomy: Assessing the impact of a standardized operation note proforma

IntroductionOperative notes are the recognized standard for documenting the details of an operation yet key procedural details are frequently missing. With the aim of improving standards, based on the Royal College of Surgeons (RCS) and Dutch Society of Surgery (DSS) Guidelines, we introduced an operation note proforma for use following laparoscopic cholecystectomy in a tertiary centre in the UK. MethodsThis study audited 130 consecutive laparoscopic cholecystectomy operation notes against accepted guidelines across three hospital sites within the same NHS Trust. Following analysis of these operation notes a standardized operation note proforma was designed and introduced across the Trust, which included all items from the DSS and RCS guidelines in the form of keyword prompts or simple yes/no responses. A further 128 operation notes were analysed. Guideline compliance was compared pre- and post-introduction of the proforma. Non-parametric data were analysed using Fisher's exact and Mann–Whitney U tests. Statistical significance was set at p < 0.05. ResultsOn a global assessment of operation note completeness against all guideline items, introduction of an operation note proforma significantly improved documentation rates for both DSS guidelines (p < 0.001) and RCS guidelines (p < 0.001). DiscussionWe have demonstrated that the introduction of a procedure-specific proforma to assist with writing the post-operative note following laparoscopic cholecystectomy can result in significant improvements in documentation of generic and procedure-specific items that should be recorded for every operation. Procedure-specific proformas, based on established guidelines can help to produce more complete and medico-legally robust operation notes.

A thorough note: Does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines?

IntroductionOperation notes provide an insight into the operative process and stand as a legal document of a surgical procedure occurring. Maintaining accurate, complete and legible notes is fundamental for post-operative patient care and medico-legal purposes. This study aimed at comparing the quality of laparoscopic appendicectomy operation notes prior-to and after the introduction of a procedure-specific proforma consistent with the Royal College of Surgeons of England (RCSEng) guidelines, 2014. MethodsNineteen parameters based on the RCSEng ‘Good Surgical Practice’ 2014 guidelines were used to audit laparoscopic appendicectomy operation notes. The study consisted of a retrospective audit of 43 consecutive laparoscopic appendicectomy operation notes and a prospective audit of 57 consecutive operation notes following the introduction of a procedure-specific proforma (existing in both hard copy and electronic versions) for laparoscopic appendicectomy.We assessed: (i) the overall compliance with the RCSEng guidelines, (ii) whether each parameter of RCSEng guidelines recommendations were clearly recorded in the operation notes, and (iii) legibility of operation notes. Statistical analysis for difference between the two groups was performed using the independent sample t-test. ResultsAfter introduction of a procedure-specific profroma for laparoscopic appendicectomy, average compliance with RCSEng guidelines increased from 66% retrospectively to 94% prospectively (p < 0.00001). In 8 of the 19 parameters assessed there was significant improvement in adherence to guidelines. DiscussionThe implementation of a procedure-specific operation significantly increased compliance with RCSEng guidelines. Such proformas may help reduce variability and standardise operation notes for the same procedure and improve post-operative care.

Improving the Quality of Oral and Maxillofacial Surgical Notes in an Indian Public Sector Hospital in Accordance with the Royal College of Surgeons Guidelines: A Completed Audit Loop Study.

Proper and adequate documentation in operation notes is a basic tool of clinical practice with medical and legal implications. An audit was done to ascertain if oral and maxillofacial surgery operative notes in an Indian public sector hospital adhered to the guidelines published by the Royal College of Surgeons England. Fifty randomly selected operative notes were evaluated against the guidelines by RCS England with regards to the essential generic components of an operation note. Additional criteria relevant to oral and Maxillofacial Surgery were also evaluated. Changes were introduced in the form of Oral and Maxillofacial Surgery specific consent forms, diagram sheets and a computerized operation note proforma containing all essential and additional criteria along with prefilled template of operative findings. Re-audit of 50 randomly selected operation notes was performed after a 6month period. In the 1st audit cycle, excellent documentation ranging from 94 to 100% was seen in 9 essential criteria. Unsatisfactory documentation was observed in criteria like assistant name, date of surgery. Most consent forms contained abbreviations and some did not provide all details. Additional criteria specific to Oral and Maxillofacial Surgery scored poorly. In the 2nd Audit for loop completion, excellent documentation was seen in almost all essential and additional criteria. Mean percentage of data point inclusion improved from 84.6 to 98.4% (0.001< P value <0.005). The use of abbreviations was seen in only 6 notes. Regular audits are now considered a mandatory quality improvement process that seeks to improve patient care and outcomes. To the best of our knowledge, this is the first completed audit on operation notes documentation in Oral and Maxillofacial Surgery from India. The introduction of a computerized operation note proforma showed excellent improvement in operation note documentation. Surgeons can follow the RCS guidelines to ensure standardization of operation notes.

Introducing a proforma to improve clinical care in trauma surgery.

Accurate trauma operative details are an important part of the care of trauma patients. This study evaluated the adequacy of handwritten operative notes for trauma patients and whether they comply with the standards set by the Royal College of Surgeons of England for optimizing clinical practice in a busy district general hospital. Fifty consecutive sets of handwritten trauma operative notes were reviewed prospectively. A standardized printed proforma was introduced and then another 50 consecutive sets of notes were reviewed. The results were analysed using the Student t-test to obtain two-tailed P values comparing the mean difference between percentages of missing data for both cycles. Out of 24 parameters examined, 19 showed improvement after introducing the standardized proforma in trauma surgical notes. There was an overall significant improvement in the studied parameters (P= 0.0134), with a mean difference of 19.3% of missing data for both cycles. These results suggest that a standardized prestructured operative note proforma in trauma surgery is a useful tool in recording the operative data, thus helping to improve the medical care provided. It would also provide medicolegally sound evidence of a procedure when needed and so be more beneficial for the surgeon if routinely used. The authors recommend its regular use in different surgical specialties.

The impact of an operative note proforma on operation note standards in a district general urology department

The impact of an operative note proforma on operation note standards in a district general urology department

The impact of an operative note proforma at a paediatric surgical centre.

With expectations for standardization and evidence-based practice, the Royal College of Surgeons (RCS) published the 'Good Surgical Practice' in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico-legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma. All general surgery and urology admissions during July 2011 and August 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in February 2012. Results were compared and statistically analysed using two-tailed Fisher's exact test, with Bonferroni correction where appropriate (SPSS 20.0, IBM SPSS Statistics, Armonk, NY, USA). There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistant's name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetist's name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% (P<0.05). Subgroup analysis in the latter cohort shows most of these effects to be related to the use of the proforma rather than education alone (P<0.05). Quality of documentation was better by consultants versus trainees in 2 of 23 criteria (P<0.05). We have demonstrated a simple and cost-effective way of improving the quality of operative documentation, in line with guidelines set out by the RCS, in a climate of increasing economic austerity.