491 Quality of Operation notes - Fit for purpose?

Abstract Aims Every doctor should maintain accurate and contemporaneous records. Operation notes with documentation are crucial for providing good medical care. This responsibility lies the primary surgeon. The aim was to assess quality of operation in accordance standards by RCS guidelines ‘Good surgical Practice.’ Methods 120 General Surgery (Electronic handwritten) were randomly identified over a period 2½ months. covered both elective emergency operations. Reviewers collected data from analysis completed clinicians. parameters that evaluated Name, Hospital number, Date, Time operation, Elective/Emergency, Procedure, Name surgeon, Assistant, Anaesthetist, Incision, Operative diagnosis, Findings, Complications, Details tissue removed, Additional procedures, Name/serial number prostheses, DVT prophylaxis, Antibiotics, Blood loss, closure/suture material, Post-op instructions signature. Results Of above parameters, 6 met standard 100%, 7 ≥ 90%, 50-89% 2 achieved < 50%. Conclusions There certain need improvement achieve 100%. Actions have been taken raise awareness essential requirements notes, facilitate compliance as well reminders ensure adherence process. will further improve notes. A re-audit subsequent these measures furnish us more information.