EP427 - Are we following the RCS England Guidelines for documentation of the operation note for a laparoscopic appendicectomy: A complete audit loop

Abstract Introduction The audit outlines the importance of adhering to RCS England Guidelines for documenting laparoscopic appendicectomies. Following these guidelines ensures standardized documentation, facilitating effective communication and promoting patient safety. Moreover, it underscores the significance of recording key procedural steps and techniques employed during the operation. It highlights the guidelines' emphasis on legible, timely, and complete documentation, emphasizing the role of the operation note as a legal document. Method This audit involved collecting data from September 2022 - August 2023 for the first loop to analyse operative notes of 92 laparoscopic appendicectomy cases. For the second loop, after introducing an electronic procedure-specific checklist as a guide, we reviewed 30 notes prospectively over a 2-month period (November-December 2023). The notes were compared against RCS England ‘Good Surgical Practice’ 2014 Guidelines using 18 parameters. We assessed for compliance with the guidelines and the legibility of notes. Results After introduction of a checklist, average compliance with guidelines increased significantly in 9 of the 18 parameters assessed, 6 remained unchanged at almost 100% compliance. Two key areas for emphasis were identified: instructions for post-op antibiotics (83%), DVT prophylaxis (53%). The most noticeable lack of documentation was in the gynaecological findings of females, recorded in only 13% of cases. There has been a noticeable effort in improving the legibility of the notes. Conclusion Introduction of a checklist increased compliance with guidelines. The comprehensive documentation will ultimately promote optimal patient outcomes and advance the overall quality of surgical care.