OGC P48 Improving documentation in Surgical Operation Notes in An Upper GI Surgery Tertiary Unit: A Quality Improvement Project

Abstract Background Good Surgical Practice are a set of guidelines that surgeons should adhere by to ensure efficiency services, patient's quality care and safety. One the standards focuses on good medical record keeping; within this standard, it is dictated there be operative notes for every procedure, where each note include following: D date time, elective/emergency names operating surgeon assistant, name theatre anaesthetist, procedure carried out, incision, diagnosis, findings, any problems/complications, extra performed reason why was performed, details tissue removed, added or altered, identification prosthesis used, including serial numbers prostheses other implanted materials, closure technique, anticipated blood loss, antibiotic prophylaxis (where applicable), DVT prophylaxis, detailed postoperative instructions signature. Methods 97 patients our tertiary Upper GI Surgery Unit were retrospectively reviewed investigate how many criteria listed in RCS adhered to. These recorded using two different template forms trust's electronic system.39 operations an old operation 2019; documentation these compared 58 newly implemented 2021. Results We found excellent with use both templates when surgery (100% vs 100%), assistant incision type findings added, altered technique 100%) 100%). Documentation poor 2019 2021 specifying whether elective emergency (5% 12%), complications/problems occurred (10% 43%) (8% 52%). However, notable improvement implementation new procedural template; especially true time (3% estimated loss (15% Conclusions detail generally reviewed, seen after more comprehensive template. There is, however, still room improvement; could achieved creating separate text boxes allowing describe elective/emergency, declare if additional procedures declare. Further actions would present results local surgical department re-review 6 months’