Improving documentation in surgical operation notes.

Background: Accurate documentation in surgical operation notes is crucial in facilitating the postoperative care of surgical patients and forms an important medicolegal document. This study audited the quality and completeness of documentation in surgical operation notes at a single district general hospital against the Royal College of Surgeons (2014) Good Surgical Practice guidelines, and looked to improve clinical practice through improved compliance with these guidelines.

Method: A total of 101 operation notes were audited from a variety of surgical specialities in November 2014 (cycle 1) and 100 notes in May 2015 (cycle 2). Documentation was audited against 19 standards found in the Royal College of Surgeons guidelines. The results were presented at the trust clinical governance meeting. Interventions included clinician education, aide memoires in theatres and the introduction of a new operation note.

Results: Six of the 19 standards had >90% compliance in cycle 1 and 12 out of 19 in cycle 2. There were dramatic improvements in documentation in many fields including time (4% to 60%, P<0.0001), elective or emergency procedure (1% to 83%, P<0.0001), problems or complications (67% to 100%, P=0.016), estimated blood loss (2% to 73%, P<0.0001), antibiotic prophylaxis (47% to 96%, P<0.0001), venous thromboembolism prophylaxis (43% to 83%, P<0.0001) and signature (78% to 97%, P<0.0001).

Conclusions: This audit has demonstrated that significant improvements in documentation in operation notes can be achieved through simple interventions. The introduction of an improved operation note that addresses each standard from the Royal College of Surgeons guidelines helped to guide clinicians to include important and relevant information.