369 Do We Need to Standardise the Neurosurgery Post-Op Note: A QI Project
نویسندگان
چکیده
Abstract Aim Accurate, informative, and consistent documentation in the postoperative period is an essential aspect enabling effective safe communication between healthcare professionals. Limited can increase risk of errors suboptimal care. The Royal College Surgeons (RCS) identified 18 criteria for operation note ‘Good Surgical Practice’, continuity Currently, structure information documented a tertiary neurosurgical department varied. aim this quality improvement project was to improve using proposed proforma. Method A proforma RCS guidelines distributed via email. Operation notes all patients undergoing procedures were compared against from November 1st – 30th, 2020, pre-proforma introduction. then re-audited July 31st post-proforma Results 66 operations group, 49 group. Date, time, details tissue alteration, operative findings, incision, prosthesis identification, antibiotic use signature well both pre post introduction (>90%). In reaudited group there anaesthetist (37 vs 24%), complications (78 35%), extra (18 2%), blood loss (22 12%), small decrease DVT prophylaxis (59 53%). Conclusions structured useful enhancing post-operative period. We create standardised template trust's note-taking system standardise process provide further training on importance documentation.
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ژورنال
عنوان ژورنال: British Journal of Surgery
سال: 2022
ISSN: ['1365-2168', '0007-1323']
DOI: https://doi.org/10.1093/bjs/znac269.331