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EP.FRI.583 Re-Audit of the Quality of Operation Notes


 
 
 High quality operation notes are crucial for the safe management of surgical patients. The Royal College of Surgeons Good Surgical Practice (2014) describes eighteen separate pieces of information that should be included in operation notes. Our aim was to determine whether the quality of operation notes have improved since the introduction in our hospital in 2015 of an electronic proforma to record these notes.
 
 
 
 We conducted a retrospective audit of operation notes between 28th October and 19th November 2020 based on the RCS guidelines. These results were compared to those of our 2015 audit.
 
 
 
 Of the seventy eight operation notes analysed in this re-audit, twenty eight percent were produced using the electronic proforma compared to forty five percent in 2015. In our re-audit a significantly higher proportion of notes had records of whether operations were elective or emergency (p < 0.01), intraoperative diagnosis (p < 0.01) and estimated blood loss (p < 0.05).Compared to the 2015 audit data there was a significant improvement in recording whether or not the surgery was elective or emergency (p < 0.0001).
 
 
 
 In this audit we noted a disappointing decrease in proportion of operation notes that were produced using the electronic proforma. We also noted that operation notes produced using the electronic proforma were of higher quality compared to those that were not. We need to increase awareness amongst surgeons in our hospital of the benefits of using the electronic proforma to improve the quality of operation notes.
