OGC P48 Improving documentation in Surgical Operation Notes in An Upper GI Surgery Tertiary Unit: A Quality Improvement Project
Authors: Choi Fiona , Oliver Lucy , Rao Rohith 
Published: December 2022

Background

Good Surgical Practice are a set of guidelines that surgeons should adhere by to ensure efficiency of services, patient's quality of care and safety. One of the standards focuses on good medical record keeping; within this standard, it is dictated that there should be operative notes for every procedure, where each note should include the following: D

date and time, elective/emergency procedure, names of the operating surgeon and assistant, name of the theatre anaesthetist, operative procedure carried out, incision, operative diagnosis, operative findings, any problems/complications, any extra procedure performed and the reason why it was performed, details of tissue removed, added or altered, identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials, details of closure technique, anticipated blood loss, antibiotic prophylaxis (where applicable), DVT prophylaxis, detailed postoperative care instructions and signature.

Methods

Surgical operative notes of 97 patients within our tertiary Upper GI Surgery Unit were retrospectively reviewed to investigate how many of the criteria listed in RCS guidelines were adhered to. These 97 operative notes were recorded using two different template forms on the trust's electronic system.39 of the operations were recorded using an old operation notes template in 2019; the documentation details of these were compared to 58 operation notes that were recorded using the newly implemented template in 2021.

Results

We found that documentation was excellent with use of both templates when including date of surgery (100% vs 100%), name of surgeon (100% vs 100%), name of assistant (100% vs 100%), operative procedure (100% vs 100%), incision type (100% vs 100%), operative findings (100% vs 100%), details of tissue removed, added, or altered (100% vs 100%), details of closure technique (100% vs 100%), DVT prophylaxis (100% vs 100%) and detailed postoperative care instructions (100% vs 100%). Documentation was poor in both the 2019 and 2021 operative notes when specifying whether procedure was elective or emergency (5% vs 12%), when specifying whether any complications/problems occurred (10% vs 43%) and whether an extra procedure was performed (8% vs 52%). However, there was notable improvement in documentation with the implementation of the new procedural note template; this was especially true for time of operation (3% vs 100%) and estimated blood loss (15% vs 100%).

Conclusions

Documentation detail was generally good in the 97 operative notes reviewed, with notable improvement seen after the implementation of a more comprehensive template. There is, however, still room for improvement; this could be achieved by creating a new template to include separate text boxes allowing the surgeon to describe whether the procedure was elective/emergency, whether there were any complications/problems to declare and if there were any additional procedures to declare. Further actions would be to present these results to the local surgical department and re-review these operation notes in 6 months’ time after implementation of new template.