EP.TU.2Standards in Operation notes

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Joshua Alfred ◽  
Simon McClean ◽  
George Nita ◽  
Frances McNicol ◽  
Suha Ugur
Keyword(s):  
Royal College ◽  
Record Keeping ◽  
Fistula Surgery ◽  
Operation Note

Abstract Guidelines exist for operation notes from the Royal College of Surgeons of England but compliance has been shown to be variable. Aim The authors performed an audit of compliance with RCS standards in a colorectal department. Methods Thirty random operation notes were selected from a conserved pool. Their compliance was recorded against RCS good surgical practise record keeping and also looked particularly at fistula surgery and there documentation. Result Compliance was found to be poor and recommendations were put in place and the following was re audited. Conclusion As some specialities are developing operation note standards specific to individual procedures, the findings are compared with previous similar published work.

An audit of basic record keeping standards: lessons learnt from the Royal College of Physicians

2008 ◽  
Vol 48 (2) ◽  
pp. 155-158 ◽  
Author(s):  
Nuwan Galappathie ◽  
Krishma Jethwa ◽  
Biljana Andonovska
Keyword(s):  
Royal College ◽  
Record Keeping ◽  
Lessons Learnt

scholarly journals 684 The Standard of Emergency Operation Note Documentation at A District General Hospital Compared Against The Royal College of Surgeons of England (RCSEng) Standard

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
S Zuberi ◽  
Y Mushtaq ◽  
K Patel ◽  
J Joseph ◽  
R Gurprashad
Keyword(s):  
General Hospital ◽  
Royal College ◽  
Emergency Operation ◽  
District General Hospital ◽  
National Standard ◽  
Average Score ◽  
Estimated Blood Loss ◽  
Operation Note ◽  
The Impact ◽  
Current Guidelines

Abstract Introduction Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma. Method A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020. Results RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p < 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p < 0.0001), estimated blood loss (2% vs 63%; p < 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p < 0.0001). Conclusions Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.

scholarly journals 99 Perfecting the Proforma – A Full-Cycle Audit on The Quality of Documentation of The Hand Trauma Proforma At the Regional Plastic Surgery Department

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A Noshirwani ◽  
B Phillips ◽  
M Hosain ◽  
K Drewniak ◽  
V Parekh ◽  
...  
Keyword(s):  
High Standard ◽  
Free Text ◽  
Hand Trauma ◽  
Record Keeping ◽  
The United Kingdom ◽  
Written Descriptions ◽  
Operation Note ◽  
Surgery Department

Abstract Aim We aimed to assess the quality of record-keeping of the departments hand trauma proforma, identify areas of improvement, and to implement and assess the quality of an updated proforma. Method Data from 101 parameters was collected for 20 patients undergoing surgery for an upper limb injury in November 2019. An updated proforma was implemented and a further 20 patients were analysed in February 2020. All fields were compared between two audit cycles and comments were collected. Results The overall completion rate increased. Documentation of the responsible consultant increased to 100%, along with an increase in documenting of hobbies and injury mechanism. X-ray findings (55% to 85%) and antibiotic plan (35% to 80%) increased. Implementation of a free text box resulted in written descriptions of injury to compliment sketches. In the operation note, documentation of anaesthetic type used increased, along with tourniquet use and time. There was clearer documentation of the injury, findings, and procedure, with greater use of diagrams to illustrate the repair. There was a drop in the recording of post-op plans (100% to 85%), post-op antibiotics (90% to 75%), and follow-up plan (95% to 60%). Clinicians commented to increase the size of the free-text box and hand diagram on the operative page to facilitate easier drawings. Conclusions The Hand Trauma Proforma has made good progress from its original version but requires further adjustments to ensure complete data input. It sets a high standard for data collection and presents itself as a useful tool for units across the United Kingdom.

scholarly journals 715 A Re-Audit of Compliance with Documentation Standards in General Surgery Operation Notes at A District General Hospital

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
O Ogundeji ◽  
S Hornby ◽  
S Dwerryhouse
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Continuity Of Care ◽  
Royal College ◽  
General Surgery ◽  
District General Hospital ◽  
Slight Improvement ◽  
Legal Document ◽  
Current Operation ◽  
Operation Note

Abstract Introduction The operation note is an important document in patient care. It is an essential part of a patient’s medical record. Apart from helping to ease the continuity of care, it is also a crucial medico-legal document. The aim of this audit was to re-assess the compliance of current operation note documentation in the department with the guidelines set out by the Royal College of Surgeons (RCS) of England. Method We carried out the re-audit 4 months after presenting the initial findings. 40 operation notes, randomly selected, were used for this audit over 6 weeks. Only operations conducted by General Surgery consultants (24) or registrars (16) were audited. Both Emergency and Elective procedures were audited (13 Emergency; 27 Elective). Results Time was still inconsistently documented in operation notes although there was a slight improvement (37%; 47.5%). Operative diagnosis was present in 82.5% of notes, compared with 78% in the first audit. 100% of notes had the signature of operating or assisting surgeon. Detailed post-operative plans were present in 95%, an improvement of 17% from the previous audit. Conclusions The quality and compliance with standards of the operation notes improved generally but there is still room for further improvement.

scholarly journals EP.FRI.489 Audit of emergency Operation notes (audit cycle)

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Nadia Gulnaz ◽  
Rami Oweis ◽  
Farooq Abdullah ◽  
Andrew Crumley ◽  
Sadia Tasleem
Keyword(s):  
Royal College ◽  
Wound Closure ◽  
Emergency Operation ◽  
Missing Information ◽  
Surgical Department ◽  
Operation Note ◽  
Operative Findings ◽  
Operative Notes ◽  
Recommended Guidelines ◽  
Incision Wound

Abstract The Royal College of surgeons has recommended guidelines for documenting operative surgical notes. An operation note must include ample information about the operation. In our initial audit, we found some areas for improvement. This re-audit of operative notes was aimed to review compliance with the guidelines by the Royal College of Surgeons and to identify areas of further improvement. Methods The notes of all patients who underwent emergency surgery from 1st of January to 15th of March 2020 under the General Surgical department were reviewed. Endoscopic procedures were not included in the study. Electronic records were used to review the operation notes. Results Notes of a total of 176 patients were included in the study. Significant improvement was seen in most of the domains. Compliance of 100% was seen in documenting operative findings, type of incision, wound closure technique, procedural details, documenting extra procedures, and post operative instructions. 17.6% notes did not clearly document the indication/diagnosis for surgery. 15.3% notes missed information about DVT prophylaxis. 25.57%notes did not include information about peri-operative antibiotics in the context of prophylaxis or post-op need. A significant number (71.6% ) of the notes were missing information about operative blood loss if there was any or none. Conclusion Overall operation notes detail most of the information expected by the Royal College of Surgeons. The key areas for improvement are to include specific details about the following:

scholarly journals 1469 Audit of Clinical Notes Filing in Vascular Surgery

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M Griffiths ◽  
A Perusseau-Lambert ◽  
A Bush ◽  
D Mittapalli
Keyword(s):  
Vascular Surgery ◽  
Medical Practice ◽  
Royal College ◽  
Quality Care ◽  
General Medical Council ◽  
Medical Council ◽  
Chronological Order ◽  
Record Keeping ◽  
Clinical Notes ◽  
Good Medical Practice

Abstract Aim Assess the correctness of patient's notes filing following the Royal College of Physicians, Record Keeping Standards, and the General Medical Council, Good Medical Practice, guidance: medical notes must be filed in the correct section, in a chronological order, three key identifiers on each page. Method Over 3 months, the general surgical wards, using case notes and those using folders for the current admission were assessed to identify loose notes. The vascular surgery patients’ notes were reviewed for the following criteria: not loose, filed in the correct section, in chronological order, and had three key identifiers. Results Surgical wards using case notes had 28.6% of the notes filed (n = 21) compared with 78.9% filed on wards with admission folders (n = 57). Within vascular surgery (n = 15), 13.3% had all notes filed, 20% were in chronological order, 6.7% had notes filed in the correct section, and 20% had key identifiers on every page. Conclusions The filing of case notes on the vascular ward resulted in loose notes more than other wards that use admission folders. To resolve this, “Admission Folders” were introduced (alongside full case notes) to assist with filing and label sheets used to assist with fast identification of current admission documents. After implementation of Admission Folders, the staff found notes easier to access and follow, according to the staff surveys, and notes were correctly filed and given identifiers, ensuring continued quality care for the patients.

scholarly journals Improving the quality of procedure-specific operation reports in orthopaedic surgery

2010 ◽  
Vol 92 (2) ◽  
pp. 159-162 ◽  
Author(s):  
Andrew W Barritt ◽  
Laura Clark ◽  
Adam MM Cohen ◽  
Naveen Hosangadi-Jayedev ◽  
Paul A Gibb
Keyword(s):  
Royal College ◽  
Orthopaedic Surgery ◽  
Outcome Measure ◽  
Study Cohort ◽  
Main Outcome Measure ◽  
Audit Cycle ◽  
Operation Note ◽  
Hemi Arthroplasty

INTRODUCTION The objectives of this study were to: (i) assess whether handwritten operation reports for hip hemi-arthroplasties adhere to The Royal College of Surgeons of England (RCSE) guidelines on surgical documentation; (ii) improve adherence to these guidelines with procedure-specific computerised operation reports; and (iii) improve the quality of documentation in surgery. PATIENTS AND METHODS Thirty-three parameters based on RCSE guidelines were used to score hip hemi-arthroplasty operation reports. The first audit cycle was performed retrospectively to assess 50 handwritten operation reports, and the second cycle prospectively to assess 30 new computerised procedure-specific operation reports produced for hip hemi-arthroplasties. Eighty patients undergoing hip hemi-arthroplasty in a department of orthopaedic surgery within a UK hospital between September 2007 and August 2008 formed the study cohort. RESULTS The main outcome measure was the average scores attained by handwritten versus computerised operation reports. Handwritten reports scored an average of 58.7%, rising significantly (P < 0.01) to 92.8% following the introduction of detailed, computerised proformas for the operation note. Adherence to each RCSE parameter was improved. CONCLUSIONS Computerised proformas reduce variability between different operation reports for the same procedure and increase their content in line with RCSE recommendations. The proformas also constitute a more robust means of operative documentation.

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