AB241. SOH26AB_0256. Surgical precision beyond the operating room—assessing note compliance in a model three hospital

Background: Surgical operation notes are an important legal document detailing the surgical indication, procedure, and post-operative plan for each patient. Ireland lacks specific national guidelines; however, the Royal College of Surgeons in England (RCSEng) outlines standards which have been adopted in Irish surgical practice, ensuring inclusion of the key points of the operative course. We assessed levels of surgical precision beyond the operating room.

Methods: A retrospective audit reviewed op-notes from three surgical teams in a model three hospital (Mayo University Hospital) in the West of Ireland. Evaluating compliance with standards outlined by RCSEng’s “Good Surgical Practice” (March 2025). Key elements included date, start and finish time, elective/emergent, staff involved (surgeon, assistants, scrub team, anaesthetics), etc. Due to the importance of this document, the standard was set to 100% compliance.

Results: Forty operation notes over 4 weeks were evaluated. No parameter achieved full compliance. Standards with the highest compliance were procedure (100%), date (97.5%), and surgeons (97.5%). Areas showing the poorest compliance were time (22.5%), medical council registration number (MCRN) (35%), and elective/emergency (67.5%).

Conclusions: Significant gaps were found in adherence to standards across all parameters analysed. This is a concerning finding, given the importance of these documents. This first audit cycle has been followed by an educational intervention with a departmental training event and displaying an example of a “model operation note” in each theatre. A re-audit is taking place to assess improvement. Following this review, if compliance remains poor, a questionnaire will be given to surgical staff to assess what barriers are leading to poor compliance with standards, and guide further action to improve quality.

Keywords: Audit; compliance; quality improvement; standards; surgical documentation