Title : Compliance of surgical operative notes to royal college of surgeons’ good surgical practice standards in ealing Hospital
Abstract:
Accurate comprehensive operative documentation is essential for patient safety, continuity of care, and medico-legal practice. The Royal College of Surgeons of England (RCSEng) outlines clear guidelines for operative notes. This ensures continuity of care by another doctor and examples but not limiting include operative diagnosis, antibiotic prophylaxis etc. This re-audit evaluated compliance of general surgical operative notes at Ealing Hospital with Royal College of Surgeons of England (RCSEng) Good Surgical Practice standards. Following an initial audit identifying significant documentation gaps, targeted interventions were implemented, including departmental teaching, email reminders, and visual prompts in theatre areas. This re-audit analyses the effects of our implementation.
A re-audit was retrospectively gathered for 100 consecutive operative notes over a 2week period over 20/09/2024- 04/10/2024 using cerner operation notes.
Despite interventions major areas of non-compliance persisted, notably documentation of elective versus emergency status, anticipated blood loss, antibiotic and DVT prophylaxis, and clinician signatures. This is crucial to ensure NICE guidelines are adhered to. Significant reduction was seen with documentation of anticipated blood loss (-33% reduction). Only 13% of documentation highlighted whether it was an elective or emergency operation. Furthermore only 29% of DVT prophylaxis was documented which was an improvement from 1st audit. This is significant given the risk of VTE. Key areas demonstrating partial improvement included identification of prostheses (42% improvement), and recording of the theatre anaesthetist. These findings highlight the ongoing need for structured documentation tools and continued education to improve operative note quality and patient safety.
