DOI: 10.1093/bjs/znad258.181 ISSN:

1097 Assessing the Compliance with RCS Operative Note Content Guidance in the General Surgical Department at a DGH With a Hybrid Note System

S James, A Arbis, R Harshen
  • Surgery

Abstract

Aim

To assess the compliance with the RCS operation note content guidance at Conquest Hospital, Hastings. Ensuring the accuracy of operation notes cannot be overstated, allowing adequate information to be obtained by team members and for medico-legal purposes. Previously, operative notes were completed on paper, with sub-headings for prompts. A few years ago, this process moved online with a blank template.

Method

Using theatreman, we retrospectively collected data beginning 13/9/22 for 100 consecutive elective or emergency operations performed by any general surgeon at Conquest Hospital. Each operation note was observed for compliance with each of the 19 points of the RCS guidelines with data compiled using an excel spreadsheet with simple statistical analysis.

Results

Overall compliance with the 19 points of the RCS guidance was 65.3%. No single operative note contained all the required 19 points. No operative note recorded estimated blood loss.

Conclusions

Compliance with the prescribed guidelines varied greatly. No single operative note contained all the required information. Moving forward, we plan to work alongside the IT team to produce a prepopulated template for the writing of operative notes. Unfortunately, due to complex nature of IT systems, this will likely take some time. In the meantime, we plan to use a template operative note adjacent to each computer screen in theatres where the notes are completed to act as a guide for surgeons when completing their documentation. Following the implementation of each of these changes, we will complete a further audit to assess for compliance.

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