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Abstract Aim Good Surgical Practice document by the Royal College of Surgeons (RCS) England emphasizes the importance of “clear operative notes for every procedure”. Importance of clear documentation is well-established. Accurate and comprehensive documentation facilitates effective handover and aids in medicolegal issues. We assess the current documentation standards for all elective cases in General Surgery between June 2023 – August 2023. We aim to identify and improve compliance of documentation in general surgery operation notes in a district general hospital. Method Mandatory operative note domains were taken from Good Surgical Practice (2014) by the RCSEng. Acceptable compliance domains =90% and poor compliance domains =50%. We performed a retrospective review of all elective operations performed between June 2023 – August 2023 in the General surgery department. Results 107 typed operation notes were identified. The department was compliant in the domains of date (94.39%), Operative surgeon (93.46%), procedure (97.20%), operative diagnosis (98.13%), operative finding (91.59%), details of operation (100%), closure technique (96.26%), post-op instructions (99.07%) and signature (100%). We saw poor compliance the domains of elective/emergency procedure (0%), complications/problems (36.45%), additional procedures (0.93%), anticipated blood loss (0.93%), antibiotic prophylaxis (28.04%) VTE prophylaxis (11.21%). Conclusions Operation notes are an essential document for post-operative care and effective handover. Appropriate use of the operation note proforma could improve patient care and compliance with RCS guideline.
Ang et al. (Mon,) studied this question.