AB066. SOH25_AB_186. An audit of emergency surgical admission documentation—do we need a surgical proforma?

Background: Admission notes are important source of clinical information. These notes provide accurate information about patient current condition, further management plan and carry a medico-legal significance. Royal College of Surgeons of England Guidelines for Clinicians on Medical Records and Notes [1994] provides a framework and benchmark on surgical admission notes. The aim of this audit is to assess the compliance of emergency surgical admission clerking as per guidelines formulated by Royal College of Surgeon of England.

Methods: All patients admitted under general surgery emergency take through emergency from 1st till 20th October 2023 were retrospectively assessed for inclusion. A total of 46 patient notes were retrieved. Emergency surgery admission notes are assessed for completeness by a validated proforma based on the Royal college of Surgeon of England. Surgical Consult notes and pediatric population (age less than 18 years) were excluded.

Results: Out of 32 criteria, only 8 criteria have completion rate of 100%. Thirteen criteria were completed between 50% to 99%. Eleven criteria were sub-optimal (less than 50% completion). In particular, activities of daily living (21%), employment (42.8%), cardiovascular exam (19.5%), respiratory exam (19.5%), height (0%), weight (0%) and urine pregnancy test (0% in child bearing age). Review of systems have poor standardization in documentation and only formally documented in 4% of patients

Conclusions: The emergency surgical admission clerking in Sligo University hospital is sub-optimal according to guidelines set by Royal College of Surgeons of England. Documentation can be improved in 21 surgically relevant parameters. Incomplete documentation is associated with increased risk of adverse event with medico-legal consequences. A standardized proforma will be formulated as per guidelines to improve the overall documentation follow by re-audit cycle in three month time.

Keywords: Admission notes; clerking; criteria; documentation; emergency