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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.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 < 0.05.On a global assessment of operation note completeness against all guideline items, introduction of an operation note proforma significantly improved documentation rates for both DSS guidelines (p < 0.001) and RCS guidelines (p < 0.001).We have demonstrated that the introduction of a procedure-specific proforma to assist with writing the post-operative note following laparoscopic cholecystectomy can result in significant improvements in documentation of generic and procedure-specific items that should be recorded for every operation. Procedure-specific proformas, based on established guidelines can help to produce more complete and medico-legally robust operation notes.

Original publication

DOI

10.1016/j.ijsu.2016.01.037

Type

Journal article

Journal

International journal of surgery (London, England)

Publication Date

03/2016

Volume

27

Pages

17 - 20

Addresses

Department of Hepatobiliary and Pancreatic Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, OX3 7LE, UK. Electronic address: davidthomson134@gmail.com.

Keywords

Humans, Cholecystectomy, Laparoscopic, Medical Records, Documentation, Guideline Adherence, Medical Audit, Practice Guidelines as Topic