Title : Emergency general surgery operative notes compliance with RCS guidelines during COVID-19 pandemic
Abstract:
The main objective of our study was to assess the compliance of surgical operative notes for all emergency surgeries in the department of general surgery during the COVID-19 pandemic, and compare our results against the standard set by the Royal College of Surgeons (RCS) of England guidelines 'Good Surgical Practice' (1). An audit was conducted in our department from January to February 2021 at Barking Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom. We analysed all operative notes, n = 50, written/typed for Emergency procedures during the pandemic, and compared them against RCS England guidelines. There were about 18 sections on the operative note on which we assessed the compliance of the department. Most of the sections had acceptable range of compliance between 97-100% and these were date, name of surgeon, name of assistant, name of procedure, incision, diagnosis, operative findings, complications, any extra procedure, details of tissue removed, details of prosthesis used, closure and signature. 2 of the sections, antibiotic prophylaxis and post-operative care, had moderate compliance between 81-90%. The areas of concern were namely time mentioned, amount of blood loss, name of anaesthetist and DVT prophylaxis, in where the compliance rate was on average about 80%. We presented our findings in the local clinical governance meeting and raised awareness amongst all within the department, as well as set up posters all over the hospital to remind surgeons of all areas that need to be mentioned in a theatre operative note. We recommend that all theatres should have up to date RCS guidelines as posters to remind all regarding standard operative note writing and, in the process, ensure better quality of patient care.
