A Re-Audit Of Compliance With Documentation Standards In General Surgery Operation Notes At A District General Hospital

Abstract Introduction The operation note is an important document in patient care. It is an essential part of a patient’s medical record. Apart from helping to ease the continuity of care, it is also a crucial medico-legal document. The aim of this audit was to re-assess the compliance of current operation note documentation in the department with the guidelines set out by the Royal College of Surgeons (RCS) of England. Method We carried out the re-audit 4 months after presenting the initial findings. 40 operation notes, randomly selected, were used for this audit over 6 weeks. Only operations conducted by General Surgery consultants (24) or registrars (16) were audited. Both Emergency and Elective procedures were audited (13 Emergency; 27 Elective). Results Time was still inconsistently documented in operation notes although there was a slight improvement (37%; 47.5%). Operative diagnosis was present in 82.5% of notes, compared with 78% in the first audit. 100% of notes had the signature of operating or assisting surgeon. Detailed post-operative plans were present in 95%, an improvement of 17% from the previous audit. Conclusions The quality and compliance with standards of the operation notes improved generally but there is still room for further improvement.