1021 Documentation in Laparoscopic Appendicectomy: Are We Getting It “Write” First Time?
E Monaghan, H Coles, N Sivasothy, M Bath, N Thin- Surgery
Abstract
Aim
The Get It Right First Time (GIRFT) initiative was introduced to improve unwarranted variations in practice and improve patient care. GIRFT have published a series of recommendations for surgeons nationwide, which includes operative documentation. We aimed to assess completeness of documentation for laparoscopic appendicectomies in a district general hospital and identify methods of improvements, based on the GIRFT recommendations.
Method
We retrospectively searched prospectively maintained theatre lists for all “Laparoscopic Appendicectomy” performed from July to November 2022, then confirmed operations against the hospital’s electronic coding. All patients of any age were included; patients with an operation note not available online were excluded. Operation note documentation was analysed against the 34 GIRFT guideline recommendations.
Results
A total of 49 patients were included in the study. 38% of operation notes concorded with the recommendations outlined by GIRFT guidelines on laparoscopic appendicectomy documentation. 43% of the operation notes did not document in accordance with the 34 points and 8% documented incompletely. The 34 GIRFT recommendations were broken down into pre-operative, intra-operative and post-operative documentation sections. Highest levels of concordance were seen within intra-operative documentation, with 46% correctly including all necessary GIRFT recommendations. Pre-operative documentation had the poorest results – 56% not documenting in accordance with GIRFT.
Conclusions
Surgeons had varying levels of concordance with the GIRFT guidelines when recording laparoscopic appendicectomy notes. We have introduced a standardised proforma, based on the GIFT guidelines, to our practice and plan to re-assess compliance to ensure optimal documentation.