150 Audit in Post-Operative Documentation in Trauma and Orthopaedic

Introduction Post operative surgical documentation is a critical component of patient care and ensures seamless communication among health care providers. In this audit we evaluated the quality of orthopaedic operative notes against the RCS-England guidelines aiming to improve adherence to these guidelines. Method We prospectively included 50 orthopaedic post-operative patients from July 20th till July 30th 2023. Adult trauma and elective procedures were included regardless of the type of the procedure. We compared the operative notes included in the audit to the RCS good surgical practice guidelines and collected data using a checklist including the parameters in the RCS guidelines. Areas with deficient documentation were highlighted for auditing. Results The first Audit cycle identified poor areas in post operative notes as the documentation of ‘emergency/elective procedure’ (25%), ‘weight bearing status following procedure’ (25%), ‘VTE instructions’ (75%), ‘follow up instructions’ (35%), ‘investigations required after procedure’ (25%), ‘instructions regarding post operative wound care’ (50%). We created a mnemonic to aid memorising the necessary post operative instructions. We’re presenting this audit in the orthopaedic department monthly M&M meeting in November and aiming to do a second Audit cycle to compare the quality of post operative documentation following the interventions implemented following the first cycle. Conclusions Post operative surgical documentation plays a pivotal role in ensuring effective patient care, enhancing patient safety, shortens their hospital stay and provides a legal protection for healthcare providers.