ThTP6.7 Are we getting it right first time: a three hundred patient audit of operation note documentation
Mohamed Ibrahim, Sayali Shirsath, Paniz Tari, Mehmet Dogan, Taner Shakir, Paul Jose- Surgery
Abstract
Aims
Collaborative recommendations from the RCS, ASGBI, and GIRFT have been published regarding documentation for inguinal hernia repair, laparoscopic cholecystectomy and appendicectomy. This is built upon foundations which aim to mitigate litigation. A series of recommendations have been made to ensure the most salient points are covered. We retrospectively audited documentation in our local unit.
Methods
Data was retrieved from electronic medical records for operation notes coded to inguinal hernia repair (laparoscopic or open), laparoscopic appendicectomy and laparoscopic cholecystectomy at our District General Hospital. Documentation was evaluated according to the 26 point GIRFT Best Practice recommendations. Data collected was grouped into standard RCS note taking conventions: pre-operative, incision, findings, procedure, closure and post-operative.
Results
300 electronic operation notes were collated from medical records for a period spanning four months. The majority (71%) of notes were written by registrars. Overall compliance with documentation for pre-operative and incision groups were 40% and 65% respectively. Documentation rates for operative findings were 60% and procedural technique was 48%. Adherence to recommendations for closure and post-operative plans were 75% and 59% respectively. Subgroup analysis revealed 96% compliance in sections which were built into the electronic operation note template compared with 44% of free text responses.
Conclusions
Documentation plays a pivotal factor in preventing litigation. We have identified inconsistencies in our local unit with regards to common general surgical procedures. Templated fields improved adherence to recommendations by over two fold. With digital operative notes becoming more commonplace, questions are raised as to whether documentation should adopt a partially templated format.