824 Assessing the Quality of Surgical Operation Notes in the General Surgery Department at a District General Hospital (QI Project)

Abstract Aim assessing the current adherence to Royal College of Surgeons (RCS) guidance on the standards of documenting operation notes. There are 18 elements that must be present on operation notes including date and time of operation, name of surgeon and anaesthetist, type of anaesthesia, findings of operation, potential complications, closure technique, information on implants and signature of the surgeon. Method The present audit was a retrospective study of patients' notes to review their operation notes. 93 operation notes that were recorded August-September 2022 were reviewed in the first cycle. The second cycle reviewed 46 operation notes in May 2023. Results The outcome of the audit showed satisfactory adherence to majority of the RCS recommendations. Time of the operation was only recorded in 9% of operation notes in the first cycle which improved to 76% in the second cycle. Only 46% of operation notes in the first cycle were signed by a surgeon which improved to 67% in the second cycle. Conclusions Areas that mainly required improvement were identified to be recording time of the operation and signature of the surgeon in the first cycle. The result of the first cycle of audit was communicated to surgeons. The electronic operation note templates were also updated. The second cycle showed a significant improvement in the quality of operation note documentation in May 2023. A continuous cycle of audit should be implemented to ensure the documentation standards are maintained.