Abstract
Background
Appendicitis is the most common abdominal emergency in England accounting for 40,000 admissions per year. The Good Surgical Practice guideline by Royal College of Surgeons England (RCSEng) defines criteria detailing what constitutes a safe and comprehensive operation note. High-quality operation notes enable continuity of care and safe post-operative management.
Aims
(1) Assess whether laparoscopic appendicectomy operation notes are adherent to RCSEng criteria. (2) Implement an operation note proforma to improve adherence. (3) Re-audit to assess effectiveness of operation note proforma.
Methods
A retrospective audit was performed measuring compliance of laparoscopic appendicectomy notes to RCSEng criteria over a 4-month period at a central London tertiary care centre. A laparoscopic appendicectomy operation note proforma was designed and implemented. Compliance to RCSEng criteria was then re-audited against RCSEng criteria, and statistical analysis performed to assess the significance of changes to compliance.
Results
The average compliance with the RCSEng guidelines after the first cycle retrospectively was 56.1%. The average compliance after implementation of the proforma was 98.2%, with above 80% of operation notes satisfying all RSCEng criteria. This was a significant 42.1% (p < 0.0001) increase in average compliance. The implementation of the proforma reduced the amount of hand-written information, saving time and improving legibility of the operation notes.
Conclusion
The implementation of an operation note proforma has the ability to significantly improve operation note quality. This simple and effective intervention to improve operation note quality has the potential to improve post-operative safety and continuity of care post laparoscopic appendicectomy.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Abbreviations
- ASA grade:
-
American Society of Anaesthesiologists Classification
- DVT:
-
Anterior commissure
- GSP:
-
Good surgical practice
- DVT:
-
Royal College of Surgeons England
References
Appendicitis | Health topics A to Z | CKS | NICE [Internet]. Cks.nice.org.uk. 2021 [cited 9 February 2021]. Available from: https://cks.nice.org.uk/topics/appendicitis/
Singh R, Chauhan R, Anwar S (2011) Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study. J Eval Clin Pract 18(3):578–580
Good Surgical Practice - Royal College of Surgeons [Internet]. Royal College of Surgeons. 2021 [cited 9 February 2021]. Available from: https://www.rcseng.ac.uk/standards-and-research/gsp/
Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient Saf Surg. 2016;10(1).
Shayah A, Agada F, Gunasekaran S et al (2007) The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard. Int J Clin Pract 61(4):677–679
Rogers B, Pleat J (2010) Is There Adequate Information on Operation Notes? The application of the Royal College of Surgeons of England guidelines. J Perioper Pract 20(9):339–342
Payne K, Jones K, Dickenson A (2011) Improving the standard of operative notes within an oral and maxillofacial surgery department, using an operative note proforma. Journal of Maxillofacial and Oral Surgery 10(3):203–208
Abbas S, Singh S, Sundran R et al (2016) A thorough note: does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines? Int J Surg Open 2:1–5
Ghani Y, Thakrar R, Kosuge D, Bates P (2014) ‘Smart’ electronic operation notes in surgery: an innovative way to improve patient care. Int J Surg 12(1):30–32
Aldoori J, Drye N, Peter M, Barrie J (2019) Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation. BMJ Open Quality 8(4):e000766
Thomas J (2009) Medical records and issues in negligence. Indian Journal of Urology 25(3):384
Hoggett L, Wright A, Wilson J. How to write an operation note. BMJ. 2017:j355.
Funding
No funding received.
Author information
Authors and Affiliations
Contributions
Miss Sachi Shah-data collection, statistical analysis, proforma design, presentation and report writing. Dr. Andrew Refalo-assisting report writing, submission and data presentation. Mr Ahmed Hammad, General Surgery SpR-audit proposal. Mr Husam Ebied-general supervisor, assisting report writing and submission.
Corresponding author
Ethics declarations
Ethical approval
GSTT Audit Committee.
Conflict of interest
No conflict of interest.
Appendix 1. Independent sample T test
Appendix 1. Independent sample T test
Unpaired t test | |
|---|---|
P value | < 0.0001 |
One- or two-tailed P value? | Two-tailed |
t, df | t = 5.046 df = 38 |
Rights and permissions
About this article
Cite this article
Shah, S., Refalo, A., Ebied, H. et al. An audit to identify adherence of laparoscopic appendicectomy operation notes to Royal College of Surgeons Good Surgical Practice standards. Ir J Med Sci 191, 825–830 (2022). https://doi.org/10.1007/s11845-021-02567-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11845-021-02567-6