EGS P29 Improving Quality of Operation Notes in General Surgery – A complete audit cycle

Abstract Background Good quality of operation notes are essential for good post-operative care, patient safety and medico-legal issues. RCSEng have guidelines on items that should be included in all notes. Guidelines state: Ensure there clear (preferably typed) operative every procedure. The accompany the into recovery to ward give sufficient detail enable continuity care by another doctor. We re-audited general surgery. Methods compared results with first cycle. Four months (1st August 30th November 2021) period consecutive were reviewed. Operation endoscopy excluded. Operations analysed documentation as per guidelines. There less operations post COVID-19, hence longer study period. After cycle, departmental presentation given education posters displayed theatres reminder. Initial plan 2nd cycle 2020 but it was not possible due COVID-19. Problems/complications, extra procedures prosthesis used included. Additional criteria reviewed was: type anaesthetic, position, indication procedure ASA grade. Results A total 239 identified. 169 emergency 70 elective cases. 193 handwritten 46 typed.The cycle: Conclusions Higher proportion during Also, higher improvement documenting elective/emergency, time, anaesthesia, indication, findings/diagnosis, details tissue removed/added/altered, blood loss, antibiotics, DVT prophylaxis. However, poorer date, name assistant, incision, closure, signature remains. Ongoing surgeons is vital improve suggest addition further headings current op-note aid-memoire introduction digital