G582(P) Operative note quality improvement – examining compliance with the royal college of surgeons of england guidelines in a paediatric general surgical unit

• Published in: Archives of disease in childhood 2015-04, Vol.100 (Suppl 3), p.A265-A266
• Main Authors: Ryan, A, Reeves, T, Kuti, K, Flett, M
• Format: Article
• Language: English
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/archdischild-2015-308599.531

ContextOperative notes should be documented "clearly, accurately and legibly" - as endorsed by the GMC's Good Medical Practice. The RCS Eng. Guidelines (2014) advocate contemporaneous, complete surgical records. This audit identified significant shortcomings in operative documentation amongst paediatric general surgical cases in a tertiary care centre. Data collection was performed by two FY1s and a Surgical Registrar.ProblemSurgical operation notes necessitate accurate documentation from both a medico-legal and professional perspective; whilst comprehensive records facilitate post-operative patient management. However; in practice they are frequently sub-standard, thus raising concerns towards patient safety. Current operative note templates within our unit fail to comply with relevant guidelines.Assessment of problem and analysis of its causesWe identified poorly-documented details within general surgical operation notes using a data collection tool incorporating pertinent, recently-published guidance. Areas for improvement included: patient's weight, type of procedure performed (i.e. emergency vs. elective), whether surgery was with or without complication, and antibiotic prophylaxis. Results attained were compared against data from previous audits of a similar nature (carried out in 2010 and 2011 respectively).InterventionOur proposed intervention involves promoting typed documentation of operative notes, whilst advocating their transition from paper text to an electronic format. We plan to achieve this through usage of a unique, pre-existing computerised system developed by a consultant within the department, which additionally populates our current Trakcare system upon document creation. We hope to educate the entire general surgical team in its practice.Furthermore, we will introduce informative posters highlighting the RCS Eng. guidelines and reiterating imperative operative details within the main theatres and day surgery unit. Letters detailing the audit's key findings and our intended strategy for change were sent to all consultants and surgical trainees.Study designProspective analysis of 138 general surgical operative notes identified over a 2-week period. We created a 26-point core checklist incorporating both RCS (Eng.) 2014 and GMC "Good Medical Practice" 2013 guidance. We then audited elective and emergency operative documentation against this standardised proforma. Data collected was subsequently evaluated once compiled onto a computerise