1168 Documentation During Upper Gastrointestinal Surgery Admission Audit

Aim Admissions in surgery is one of the most important part of the patient care pathway and sets the trajectory for the rest of their stay. Without good documentation, the decisions made can be missed out and this will eventually lead to deficiency in the patient’s management. In this audit we aim to analyse documentation during admissions and look at ways to improve them. Method A retrospective review of documentation done during the admission for 50 random admissions in upper gastrointestinal surgery was assessed using the principles from Take Ten and the Shine Toolkit. Change implemented before second audit cycle: lecture at induction on how surgical assessment unit works, how admission and post-take ward round work, how to document & clarifications of job roles. The percentage of documentation was determined and going to be presented in a local audit meeting. Results 1st Audit Cycle vs 2nd Audit Cycle as percentage for documentation of History of Presenting Complaint (100%, 100%), NEWS (46%, 54%), Examination findings (96%, 94%), Diagnosis / Impression (94%, 94%), Advise to Patients (0%, 16%), Medication (42%, 54%) and Name of Clinician (60%, 72%). Conclusions The documentation during Surgical Admission improved in most areas and thus help lead to more safe and efficient patient care. However, there is still significant work that needs to be done. Further recommendations include implementing the Surgical Assessment for Emergencies (SAFE) Ward Round Tool, using electronic notes and availability of more computer on wheels.