ABSTRACT
Aim: Surgical handover aims to convey accurate, appropriate & concise clinical information that is correct and up to date. It is essential in providing continuity of care, ensuring patient safety, and avoiding clinical errors. This process should be led by the Consultant on call. In this audit we aimed to compare our handover documentation practice against guidelines formulated by RCS England. Method: Surgical Handover sheets from September 2020 and March 2021 were used for data collection. A total of 66 & 41 new patients were included in the initial and re audit respectively. Essential and desirable criteria guidelines by RCS England were used to compare our documentation. Essential criteria documentation should be 100% as per RCS guidelines. Results: Initial audit showed room for improvement in documentation of both essential & desirable criteria. A new handover template was introduced, we displayed posters and sent email reminders of the RCS guidelines. Re audit showed significant improvement in essential criteria: date of admission 47% to 60%, responsible consultant 0 to 100%, current diagnosis 83% to 100% and investigations 84% to 100%. In desirable criteria: Past medical documentation improved from 42 to 62%, management plans from 96 to 100% and COVID status from 52 to 79%, VTE was documented in 58% of patients. Conclusions: Surgical Handover documentation improved after implementation of changes. Busy ward rounds, multiple clinicians leading rounds, frequent relocation of patients and patients in non-surgical wards can make the process complex.