AB198. SOH21AS194. Post-operative care instructions: are we doing enough?

Background: Good documentation of orthopaedic post-operative care instructions are crucial for the seamless transfer of patient care from the operating room to outpatient clinic. It is also important for medicolegal purposes. However, it is found that these instructions are not well documented in this Irish Orthopaedic department. This causes significant confusion of patient care pathway from the operative room to out-patient clinic.

Methods: Departmental standards were set based on the Royal College of Surgeons (RCS) in England Good Surgical Practice (GSP) guidelines and a survey completed by all orthopaedic consultants in this tertiary referral hospital, of which we then measured our practice against. A retrospective audit on the post-op instructions on operative notes was undertaken for all orthopaedic trauma surgeries over a 10-day period. A closed loop audit was performed following introduction of a printed post-op care instructions proforma and education.

Results: General improvement in documentation of post-op care instructions across all 9 standards. Most notable improvements include: type of antibiotics written in 75% (12% previously), analgesia mentioned in 95% (46% previously), duration of DVT prophylaxis in 71% (0% previously), post-op bloods mentioned in 100% where indicated (50% previously), documentation of IMC /bleep number in 86% (38% previously), and removal of sutures mentioned in 73% where indicated (31% previously).

Conclusions: The introduction of a proforma serves as a checklist to the surgeon writing the operative note, and is therefore less likely to miss out important post-operative care instructions as compared to freehand written notes. Our results show a vast improvement of the quality of notes overall.

Keywords: Instructions; operative note; orthopaedics; post-operative care; documentation