1021 Documentation in Laparoscopic Appendicectomy: Are We Getting It “Write” First Time?
نویسندگان
چکیده
Abstract Aim The Get It Right First Time (GIRFT) initiative was introduced to improve unwarranted variations in practice and patient care. GIRFT have published a series of recommendations for surgeons nationwide, which includes operative documentation. We aimed assess completeness documentation laparoscopic appendicectomies district general hospital identify methods improvements, based on the recommendations. Method retrospectively searched prospectively maintained theatre lists all “Laparoscopic Appendicectomy” performed from July November 2022, then confirmed operations against hospital’s electronic coding. All patients any age were included; with an operation note not available online excluded. Operation analysed 34 guideline Results A total 49 included study. 38% notes concorded outlined by guidelines appendicectomy 43% did document accordance points 8% documented incompletely. broken down into pre-operative, intra-operative post-operative sections. Highest levels concordance seen within documentation, 46% correctly including necessary Pre-operative had poorest results – 56% documenting GIRFT. Conclusions Surgeons varying when recording notes. standardised proforma, GIFT guidelines, our plan re-assess compliance ensure optimal
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ژورنال
عنوان ژورنال: British Journal of Surgery
سال: 2023
ISSN: ['1365-2168', '0007-1323']
DOI: https://doi.org/10.1093/bjs/znad258.170