336 Elective Operative Note Compliance in General Surgery

Abstract Aim Good Surgical Practice document by the Royal College of Surgeons (RCS) England emphasizes the importance of “clear operative notes for every procedure”. Importance of clear documentation is well-established. Accurate and comprehensive documentation facilitates effective handover and aids in medicolegal issues. We assess the current documentation standards for all elective cases in General Surgery between June 2023 – August 2023. We aim to identify and improve compliance of documentation in general surgery operation notes in a district general hospital. Method Mandatory operative note domains were taken from Good Surgical Practice (2014) by the RCSEng. Acceptable compliance domains =90% and poor compliance domains =50%. We performed a retrospective review of all elective operations performed between June 2023 – August 2023 in the General surgery department. Results 107 typed operation notes were identified. The department was compliant in the domains of date (94.39%), Operative surgeon (93.46%), procedure (97.20%), operative diagnosis (98.13%), operative finding (91.59%), details of operation (100%), closure technique (96.26%), post-op instructions (99.07%) and signature (100%). We saw poor compliance the domains of elective/emergency procedure (0%), complications/problems (36.45%), additional procedures (0.93%), anticipated blood loss (0.93%), antibiotic prophylaxis (28.04%) VTE prophylaxis (11.21%). Conclusions Operation notes are an essential document for post-operative care and effective handover. Appropriate use of the operation note proforma could improve patient care and compliance with RCS guideline.