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Abstract Aims Laparoscopic cholecystectomy is one of the most common operations performed in the UK, with approximately 65,000 procedures performed per year. The operation note is of utmost importance as is documents the procedural steps, highlights peri-operative complications, details post-operative instructions and may act as medico-legal evidence if necessary. At our centre, operation notes are written using a blank online document and we aimed to make the process of writing these documents following laparoscopic cholecystectomy easier and more efficient. Methods We produced a computer based, standardised operation note for laparoscopic cholecystectomy. The document consisted of spaces for key clinical information such as the staff members involved with the operation, whether the procedure was done as an elective or emergency case and the patient’s ASA score. The document also outlined the key operative steps that could be ticked off using yes/no answers, a section for white space answers for additional details and pre-written post operative instructions that could be added to. Results This standardised operation note was well received by colleagues and facilitates rapid and thorough documentation. It ensures all steps are documented and so reduces the risk of omissions. Furthermore, it ensures legibility should it need to be referred to in the future, ensuring medico-legal compliance. Conclusions This operation note is medico-legally more rigorous, ensures legibility and is easier to use for auditing purposes. Producing the document was also an excellent trainee opportunity as it encouraged consideration of the important operative steps and outlining them in a step wise format.
James et al. (Sun,) studied this question.