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INTRODUCTION: Operative notes are the recognized standard for documenting the details of an operation yet key procedural details are frequently missing. With the aim of improving standards, based on the Royal College of Surgeons (RCS) and Dutch Society of Surgery (DSS) Guidelines, we introduced an operation note proforma for use following laparoscopic cholecystectomy in a tertiary centre in the UK. METHODS: This study audited 130 consecutive laparoscopic cholecystectomy operation notes against accepted guidelines across three hospital sites within the same NHS Trust. Following analysis of these operation notes a standardized operation note proforma was designed and introduced across the Trust, which included all items from the DSS and RCS guidelines in the form of keyword prompts or simple yes/no responses. A further 128 operation notes were analysed. Guideline compliance was compared pre- and post-introduction of the proforma. Non-parametric data were analysed using Fisher's exact and Mann-Whitney U tests. Statistical significance was set at p 

Original publication




Journal article


Int j surg

Publication Date





17 - 20


Cholecystectomy, Documentation, Laparoscopy, Operation note, Proforma, Cholecystectomy, Laparoscopic, Documentation, Guideline Adherence, Humans, Medical Audit, Medical Records, Practice Guidelines as Topic