Admissible or Overkill - Get It Right First Time (GIRFT) operative documentation for Laparoscopic Cholecystectomy

Abstract Aim Get It Right First Time (GIRFT) Laparoscopic Cholecystectomy (LC) documentation best practice was updated in September 2022. This was a combined incentive by NHS & Royal College of Surgeons with the aim to improve poor operative documentation leading to medico-legal claims and preventing defence of good medical practice. We aim was to assess how we locally adhere to these. Method Retrospective 2-cycle, 2-month review of all LC (August 2022 (pre GIRFT) and September 2022 (post GIRFT)). Operation notes were scrutinised and compared to the newly set national standards. 60 operation notes were sampled (33 pre, 27 post), completed by 8 surgeons. We defined the recommendations into 24 essential and 8 non-essential elements. Results N = 0 operative notes contained 100% of the required information recommended by GIFRT. Of the pre GIRFT, 33% (n = 11) had ≥75% of the essential criteria (p = 0.162). Post GIRFT, 44% (n = 12) had ≥75% of the essential criteria (p = 0.097). Notable deviation from standards were poor documentation on patient position & skin preparation (23%), intra-abdominal pressure setting (7%) and histology sent (3%). 0% stated the table position (reverse Trendelenburg or right side up). Conclusions Although the GIFRT guidelines for documentation in LC are lengthy, without them it is difficult to defend good medical practice when exposed to medico-legal claims. Despite GIFRT release, locally we only had minor improvements in documentation standards. This indicates that a set operation notes proforma and further dissemination of these recommendations may be needed to improve documentation standards.