AB152. SOH21AS113. Standards in operative notes—quality assessment of operative notes in oncological breast surgery: an audit and quality improvement plan

Background: Accurate operative notes contain pertinent information required for high quality patient care as well as information required for medical legal practice and research. To address deficiencies in operative notes the Royal College of Surgeons (RCS) have published clear guidelines on the criteria to be included in operative notes. The aim of this study is to assess the quality of oncological breast operative notes and to evaluate the need for a proforma to improve quality.

Methods: Surgical operative notes were audited in an Irish teaching hospital between January and December of 2019. A retrospective database of operative notes was created and maintained. Analysis of 68 operative notes was performed. Quality was assessed by adherence to the 18 criteria recommended in the RCS guidelines.

Results: An average compliance of 68% (42–85%) was achieved across all 68 audited operative notes. Eighty percent of operative notes were completed by consultants and 20% NCHDs. NCHDs scored significantly on average 64% and consultants 58%. Compliance with the RCS criteria was highest for date of procedure, and lowest for anticipated blood loss.

Conclusions: Operative notes are deficient in critical information needed to deliver high quality patient care. The underutilisation of proforma based and electronic operative notes may be a causative factor. Results are anticipated to improve with the above interventions and educational intervention.

Keywords: Documentation; mastectomy; operative note; quality of care; quality improvement