469 Operation Notes Audit: Excellent Bridge in Continuity of Care

Abstract Background Operation notes are vital as part of patient care in-line with Good Medical Practice to provide excellent continuity of care and for medicolegal purposes. This also to raise awareness on existing guidelines and accuracy of operation note documentation. Aim To assess compliance of op-notes documentation against Royal College of Surgeons (England) Good Surgical Practice Guidelines “1.3 Record your work clearly, accurately and legibly” in ENT Department Imperial College NHS. Method This is a retrospective 2-cycles audit (n=27) analysing October 2023 theatre list for first cycle and November 2023 theatre list for second cycle. Inclusion and exclusion criteria applied to ensure uniformity of data collected based on type of operations. Data documentation analysed against domains in RCS guidelines. Results Results are compared for both cycles, for which the results of first cycle were presented in a regional meeting. Almost all domains achieved 100% compliance of documentation except deep vein thrombosis (DVT) prophylaxis (10%), blood loss (5%), antibiotic prophylaxis (85%) and anaesthetists name (50%). Part of the discussion is that blood loss should be documented even in minor cases with minor bleeding risk. DVT prophylaxis might be overlooked in some cases (e.g., hemithyroidectomy which require only overnight inpatient). Conclusions Surgical teams are responsible in documenting clear plans and instructions peri-operatively to provide optimum level of patient care, reduce perioperative complications, improve patient satisfaction and ensuring patient safety.