Key points are not available for this paper at this time.
Abstract Aim Operation notes are essential in ensuring continuity of care across different clinicians and admissions. 88% of NHS trusts have Electronic Patient Record (EPR) systems, however, 75% remain reliant on paper documentation. The Royal College of Surgeons of England details Good Surgical Practice standards which include clear and accessible operation notes. This audit aimed to measure and improve adherence to these standards in our trust, which uses a mix of paper and EPR systems. Method A retrospective analysis was performed on all general surgical procedures performed in Barking, Havering and Redbridge University Hospitals Foundation Trust (BHRUT) from 01 July to 19 July 2023. Data on the type of procedure, availability of the operative note on EPR, and mode of documentation was collected. A decision for early intervention was made, and a re-audit was started prospectively from 16 November 2023. Results 197 operations were included, with 64% elective, and 36% emergency procedures. 54.8% (n= 108) had operative notes uploaded onto EPR, and 56.4% of these were typed. Following intervention, 126 operations were included in the re-audit, with 63.5% elective and 36.5% emergency procedures. 64.3% (n=81) were uploaded, and 59.3% were typed. Conclusions Adherence to national standards for operative documentation were suboptimal. Operative notes were not consistently uploaded onto EPR for accessibility and continuity of care beyond theatre. Early intervention including education of surgical juniors and troubleshooting of IT issues can help bridge the gap caused by the mixed use of paper and EPR systems. Current re-audit data appears promising with regards to improved adherence.
Tan et al. (Mon,) studied this question.