ThP7.17 - Improving completeness of operative notes for laparoscopic appendicectomy

Abstract Aim This study aimed to compare the quality of laparoscopic appendicectomy operation notes in the emergency setting to 'Get It Right First Time' (GIRFT) guidelines. To evaluate the effect of the teaching session and operative note checklist in improving the completion rate of operation notes for laparoscopic appendicectomy. Method Retrospective analysis of 19 consecutive operation notes of patients undergoing emergency laparoscopic appendicectomy. Prospective data was then collected on 15 consecutive appendicectomy operation notes post-intervention. 34 recommendations based on GIRFT recommendations 'Best practice for laparoscopic appendicectomy documentation' were used to audit laparoscopic appendicectomy operation notes. Documentation was reviewed by two independent reviewers and scores were given based on GIRFT recommendations. Student's T-test was used to calculate the significance of overall scores and Chi-Squared to calculate the difference between individual categories. Results Mean completeness of operation notes improved from the first cycle (58.5%) to the second cycle (85.5%, P<0.001). There was a significant improvement in documentation of patient positioning (P=0.001), skin preparation (0.035), diagnostic findings (P<0.001), health of caecum (P<0.036), extraction port (P=0.01) and follow-up plan (P=0.03). Conclusion There were many domains of the GIRFT recommendations not addressed prior to this audit. Teaching sessions and checklist distribution lead to a significant improvement in overall completeness of the operation note. Movement towards digitised templates should be made to further comply with guidelines.