Abstract Aim Operation notes serve as the standard documentation of intraoperative findings. The Royal College of Surgeons of England (RCS) and NHS England introduced the Getting It Right First Time (GIRFT) program, outlining 32 essential components for operation notes. This study evaluates the quality of laparoscopic cholecystectomy operation notes before and after implementing GIRFT recommendations. Methods A retrospective analysis of laparoscopic cholecystectomy operation notes from two biliary surgeons over a two-year period was conducted. Following the first audit cycle, GIRFT recommendations were implemented. Operation notes were then reassessed and compared before and after adopting these recommendations. Results A total of 245 operation notes were included. There were 132 operation notes in the first cycle and 113 in second cycle. All operation notes included 19 out of 32 recommended points, such as operation indication, consent, date/time of operation, surgical checklist, skin preparation and drugs administered. Further details are specified in the table below. Cycle 1 (n=132)Cycle 2 (n=113)Median GIRFT score27 (IQR 26-29)30 (IQR 29-32)All (32) GIRFT points included037 (32.7%)Laparoscopic pressure settings095 (84.1%)Laparoscope under direct vision2 (1.5%)77 (68.1%)Reverse Trendelenburg Position4 (3.0%)79 (69.9%)Intraoperative Pictures94 (71.2%)88 (77.9%) Discussion This study demonstrates improved quality of operation notes following the implementation of GIRFT guidelines. Adopting these standards should be encouraged and integrated into surgical training to enhance consistency and patient care. Additionally, incorporating instant digital upload of intraoperative photos could further improve documentation and prevent data loss.
Tan et al. (Fri,) studied this question.