EGS SO16 - Retrospective review of adherence of emergency theatres operation notes to Royal College of Surgeons in England Guidelines

Abstract Background Adherence to standardized operation note guidelines is crucial for ensuring patient safety and maintaining high standards of surgical practice. This study aims to evaluate the compliance of emergency theatre operation notes with the Royal College of Surgeons in England guidelines, identifying areas for improvement to enhance documentation practices. Method A retrospective review of 50 patients was conducted on operation notes from emergency theatres. The notes were assessed for adherence to the Royal College of Surgeons in England guidelines. Parameters evaluated included completeness of patient information, surgical procedure details, intraoperative findings, and postoperative instructions. Results There was good compliance in sections such as the name of the operative and assistance, operative findings, and closure. However, improvements are needed in sections such as problems encountered, anticipated blood loss, and the name of antibiotics used. Compliance can be improved by making the notes clearer and more comprehensive. Conclusion Our analysis suggests room for improvement in adherence to postoperative surgical note guidelines. We recommend adding further details such as the name of the scrub nurse, indication, to the operative notes. A postoperative checklist template has been devised to ensure adherence to guidelines and improve documentation practices.