AB135. SOH23ABS_119. Compliance to operation note standards in the general surgery department in Connolly Hospital Blanchardstown: learning points

Background: An operation note is a key aspect of surgical practice, guiding post-operative care, future decision-making, and is critical in litigation. Education regarding proper documentation however is neglected. There is currently no Irish guideline. The Royal College of Surgeons in England have set a standard in Good Surgical Practice [2014] but compliance has shown to be variable.

Methods: An audit was undertaken in our General Surgery Department. Only patients who underwent an operation under General Surgery were included. Charts were reviewed from the surgical wards and theatre by one author for compliance to the 15 data points set in Royal College of Surgeons (RCS) Guidelines. Educational interventions were made following cycle 1.

Results: Poor compliance was particularly noted in recording the time and the elective/emergency status. Compliance was excellent in areas that were clearly headed on the op-note template and conversely where there were no set heading. Broadly, improvement was seen following the educational intervention in most data points. There was a 10% improvement in legibility, leaving still a 20% of notes that are illegible.

Conclusions: Compliance was good across most points in the The Recreational Craft Sectoral Group (RSG) guidelines. Poor compliance was worst in time and elective/emergency status, which weren’t clearly headed. Legibility was poor, irrespective of the seniority of the authors. We suggest a more detailed template to improve compliance and resultant potential patient care.

Keywords: Audit; surgery; operation; notes; documentation