AB027. SOH23ABS_104. Compliance to operation note standards, learning points from a closed loop audit
General Surgery I Session

AB027. SOH23ABS_104. Compliance to operation note standards, learning points from a closed loop audit

Dhruv Kapoor1,2, Rakesh Ahmed1,2, Adrian Lopez Campillo1,2, Kian Monahan1,2, Aisling Daly2, Laura Bruen2, Claire Donohoe2

1Department of General Surgery, St James’s Hospital, Dublin, Ireland; 2Department of Upper Gastrointestinal Surgery, St James’s Hospital, Dublin, Ireland

Background: The operation note is a key aspect of surgical practice. Despite this, education regarding operation note documentation is often neglected. The aim of this audit was to assess compliance to Royal College of England (RCSEng) standards at the general surgery department in St James’s Hospital.

Methods: A closed loop audit was completed from January to September 2022. The RCSEng 2014 guidance for good surgical practice was the standard used. In the first cycle, 98 general surgery operation notes were collected retrospectively. A thorough educational intervention was implemented. A further 100 operation notes were analysed post intervention.

Results: Pre and post intervention, documentation compliance in the following areas was over 85%: date; operation title; surgeon name and signature; incision; details of tissue removed; complications; use of prosthesis; any extra procedures and closure technique. Documentation of a post op venous thromboembolism (VTE) prophylaxis plan increased from 26% to 71% post intervention. In total, 153 notes were written by registrars, 39 by consultants and 6 by senior house officers.

Conclusions: Documentation of a post-op VTE strategy is essential in the management of surgical patients. As a result of this audit, a dropdown heading making documentation of a post-op VTE prophylaxis plan compulsory has been added to the electronic operation note. Documenting the serial number of a prosthesis is particularly important in terms of quality control. The results of this audit can be used as an educational tool and are translational across specialties.

Keywords: General surgery; audit; upper gastrointestinal surgery; quality improvement; Clexane


Funding: None.


Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

doi: 10.21037/map-23-ab027
Cite this abstract as: Kapoor D, Ahmed R, Campillo AL, Monahan K, Daly A, Bruen L, Donohoe C. AB027. SOH23ABS_104. Compliance to operation note standards, learning points from a closed loop audit. Mesentery Peritoneum 2023;7:AB027.

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