Surgical operation note audit

ABSTRACT

Introduction: Medical record keeping is a fundamental part of the GMC's Good Medical Practice [1,2]. Surgeons must ensure accurate, comprehensive, and legible records are maintained [3]. An operation note is essential to ensure continuity of care between operating team and other colleagues and provides a medicolegal record of a patient's care [4]. Handover errors have been implicated in as many as 80% of sentinel events [5], highlighting the importance of ensuring accurate record keeping. Method: We aimed to assess compliance of surgical operation notes against the Royal College of Surgeons guidance and identified areas for improvement. 48 operation notes were reviewed at a district general hospital in the west midlands over two weeks. Operation notes on standard intranet proforma and custom operation notes were compared to determine better compliance. Results: We identified areas of most compliance vs areas of least compliance. Most and least compliant outcomes are listed below • Name of operation, operative findings, post-operative instructions, and incision type - 100%. • Date of operation and name of operating surgeon - 98% time. • Operating assistant -96%. • Post-operative VTE plan intraoperative antibiotic use - 73% • Time of operation and details of tissue removed - 69% • Postoperative complications - 7% Conclusions: Good compliance was noted. Using the proforma on the intranet resulted in higher compliance than custom notes (84% vs 53% respectively). Adding a complications section to standard proforma can increase compliance. This audit was performed during COVID-19 restrictions therefore investigated emergency operation notes only which limited the audit.