AB164. Audit of emergency surgical admissions note-taking: first phase of audit cycle

Background: Precise and consistent surgical admission notes provide vital information regarding the patients’ aiding management and improving outcomes.1,2,3 We aim to audit the current adherence to guidelines in freehand note-taking practice of all acute general surgical patients in Letterkenny University Hospital.

Methods: A retrospective review of all patients clerked on acute presentation was carried out between January and March 2019 for a randomly selected day during two consecutive on call weeks for all consultants. The patients clerked by physicians involved in the study were excluded along with two missing files. Data was analysed for compliance with 32 criteria proposed by the Royal College of Surgeons in England guidelines along with 22 criteria recommended by consultants.

Results: A total of 63 patient records were examined. Mean adherence to guidelines for surgical admissions was 34%.

Conclusions: We conclude that the current free hand note-taking practice in clerking emergency admissions in Letterkenny hospital is below recommended standards and a proforma would improve standardisation and accuracy of patient records leading to better outcomes

Keywords: Surgical admission; clerking; note-taking; proforma