592 Standardising General Surgery Operation Notes According to Royal College of Surgeons England Guidelines

Abstract Aim In this audit cycle, we assessed the quality of operation notes in both emergency and elective general surgery operations against the standards set by the Royal College of Surgeons of England. We particularly focussed on improving documentation with respect to operative diagnosis, estimated blood loss, whether it was an elective or emergency procedure and documentation of VTE prophylaxis in the post operative instructions. Method We collected data over a ten-day period of all elective and emergency general surgery theatre cases looking specifically at the four domains listed above. Following this we sent department wide emails and placed posters strategically next to the general surgery theatre computers where operation notes are written. Once this was done, we looked at the quality of documentation over a further ten-day period to see if our compliance with Royal College of Surgeons Guidelines had improved. Results Our compliance in regard to documentation of operative diagnosis improved from 34.88% to 60.53%. Estimated blood loss rose to 36.84% from 0%. 15.79% of operation notes included the type of procedure from 4.60% pre intervention and finally 61.54% of post operative plans now included VTE prophylaxis compared with 30% pre intervention. Conclusions Simple measures such as posters and department wide emails have slightly improved our compliance with national guidelines, but there is still some way to go. Our next steps will include forming proformas with the necessary information included to aid surgeons to document the necessary details for medico-legal, research and audit purposes.