Abstract Aim Accurate and comprehensive operative notes are essential for effective clinical communication and serve as valuable documentation for reviewing surgical procedures. This audit evaluates the quality of laparoscopic appendicectomy (LA) operation notes at our hospital against the best practice guidelines set by Getting It Right First Time (GIRFT), Royal College of Surgeons England (RCS), and the Association of Surgeons of Great Britain and Ireland (ASGBI). Methods A retrospective review of LA notes (n=29) between June and July 2024 was conducted. Following this, areas for improvement were identified, leading to the development of a standardised proforma and an educational poster to enhance documentation practices. This first cycle was presented at our departmental meeting. Copies of the educational poster and standardised proforma were displayed in the surgeons’ room. A second data collection cycle was undertaken between October and November 2024 (n=27) to determine the impact of these interventions. Results Out of the 31 measured variables recommended to be included in operation notes we found that 19 variables were included in less than 70% of notes in the first cycle. After our interventions, there were overall improvements in documentation across 26 out of 31 (89.7%) measurable variables. Moreover only 7 variables had an inclusion rate of less than 70%. While most domains showed progress, minor gaps remained in documenting appendix location and arterial division methods. Conclusion This audit highlights the effectiveness of the newly implemented proforma and poster in achieving better adherence to the guidelines. Accurate documentation is essential for good clinical practice and patient care.
Thakrar et al. (Fri,) studied this question.