310 Documentation and Consent Audit in HPB Patients

Aim Investigating documented information relating to the care of the hepatobiliary patients to ensure record-keeping standards are being met and written consent for procedures are recorded in accordance to trust and national guidance. Method 17 patient files, selected at random, were included in this audit. Microsoft Forms application was utilised to complete the data collection. The files were audited against trust guidelines regarding documentation and consent. Results Although all entries were legible and signed oftentimes GMC number and designation was omitted (81%). Allergy status and drug history had also been omitted from most records (62 and 63% respectively). Regarding consent, all forms were present in the notes, and all properly described the name/ benefits/ risks of the procedure. In 77% of consent forms, it was not documented whether an information leaflet has been provided to the patient. Only the minority of patients received a carbon copy of their consent form (23%). When the carbon copy remained in the patient’s file, the consenter had failed to circle “no” indicating patient did not accept the copy in every case. Abbreviations were used in over half of the consent forms audited (54%). Conclusions Key areas for improvement in documentation and consent were underlined by this audit. Proper and clear highlighting of patient’s allergies and drug histories is an important area for improvement regarding documentation. Consenters should make more efforts to offer patient information leaflets and carbon copies of consent forms to patients and to document this appropriately.