AB134. SOH24AB_090. Compliance in completing operation sheet at Midlands Regional Hospital Portlaoise: a service improvement audit

Background: Ensuring accurate and comprehensive documentation of surgical procedures is a vital part of medical record keeping. In this audit we assessed whether the information recorded on the operation sheet was in accordance with the “Good Surgical Practice” guidelines set by the Royal College of Surgeons (RCS) which state that surgeons must ensure that there are clear operation notes for every procedure which should contain sufficient detail to enable continuity of care by another doctor.

Methods: A sample of 20 operation sheets were selected from the Midlands Regional Hospital in Portlaoise (MRHP) and retrospectively examined by 3 reviewers to ensure compliance with the RCS guidelines. Our objective included identifying common areas of non-compliance to implement changes to the operation sheet to increase compliance.

Results: Our audit revealed overall compliance of 80% using the RCS guideline on ‘Good Surgical Practice’ and identified some common areas that were commonly documented including complications and whether appropriate prophylaxis was given. We also identified some headings that were not included on the operation sheet including whether the operation was an elective vs. emergency procedure and expected volume loss from the procedure.

Conclusions: While overall compliance was high there were some headings recommended on the guideline that did not feature on the operation sheet in MRHP. Therefore, updating of the operation sheet would be beneficial in increasing compliance with the guideline and improve patient safety and care. This should then then be re-audited in 3 months to re-evaluate compliance levels and maintain the standards set out in the RCS guideline.

Keywords: Best practice; compliance; operation sheet; retrospectively; standards