Title : From table to template: Standardizing appendicectomy documentation to enhance compliance with national standards
Abstract:
Background: Laparoscopic appendicectomy is among the most commonly performed emergency general surgical procedures and is often documented by junior surgeons. High-quality operation note documentation is essential to guide multidisciplinary care, facilitate communication and support clinical governance. National standards from Get It Right First Time (GIRFT), the Royal College of Surgeons (RCS), and the Association of Surgeons of Great Britain and Ireland (ASGBI) provide benchmarks for documentation quality.
Aim: To assess and improve the quality of laparoscopic appendicectomy operation note documentation in our general surgery department.
Methods: Operation notes for all laparoscopic appendicectomies performed between August and October 2024 were retrospectively reviewed. Notes were evaluated against documentation standards recommended by GIRFT, RCS, and the ASGBI, focusing on pre-operative, intra-operative and post-operative documentation domains. Following baseline audit, targeted interventions were implemented, including the introduction of a standardised operation note template, dissemination of educational posters, and focused teaching sessions for junior doctors. A re-audit was conducted on operation notes from April and May 2025 to assess improvement.
Results: Documentation compliance improved across all assessed domains following interventions. Pre-operative documentation increased from 60% to 67%, intra-operative documentation from 54% to 66%, and post-operative plan documentation from 40% to 50%. Despite improvements, post-operative plan documentation remained the least compliant domain.
Conclusion: Targeted, multidisciplinary interventions led to measurable improvements in the quality of laparoscopic appendicectomy operation notes. Ongoing education and reinforcement, particularly focused on post-operative planning documentation, are necessary to achieve full adherence to national documentation standards. These strategies represent scalable methods for improving surgical documentation quality and patient care continuity in emergency general surgery.
