1138 A Closed Loop Audit of Laparoscopic Appendicectomy Documentation with the Introduction of an Operation Note Template to Improve Adherence to the 2022 GIRFT Guidelines

Abstract Aim This audit aimed to assess documentation of laparoscopic appendicectomies and measure the effect of introducing an electronic operation note template. Operation documentation is of great importance to patient care, clinical communication, facilitating research and providing a legal record. In 2022, GIRFT, RCS and ASGBI produced the ‘Best practice for Laparoscopic Appendicectomy Documentation guideline (September 2022) which contained forty-four recommendations. Method Between 1st June 2022 and 30th September 2022, 99 laparoscopic appendicectomies were performed at Broomfield Hospital, Essex whose operation notes were appropriate to be audited against the GIRFT guideline. Subsequently, an operation note template was designed on Microsoft Word using the guideline and refined with feedback from stakeholders including the surgeons who would be using it. The template was rolled out across the general surgery department in November 2022. Laparoscopic appendicectomies carried out between 1st December 2022 and 31st March 2023 were then reaudited. Results Between June and September 2022, prior to the introduction of the template, the average adherence to the guideline was 35%. Between December 2022 and March 2023, the average adherence was 55%, but was 89% in operation notes which used the template. Positive feedback on the template included ease of use and reduced time to complete compared to typing on a blank document. Conclusions This audit has demonstrated the important role templates play in significantly improving documentation and adherence to guidelines which positively affects patient care. The improvement in adherence even when the template was not used is likely due to the heightened awareness of the guideline.