326 Are GIRFT Standards Being Met? a Comparative Audit of Cholecystectomy Operation Notes by Biliary and Non-Biliary Surgeons

Abstract Aim High-quality operation notes are vital for safe post-operative care, effective communication, and medico-legal protection. The RCSEng and GIRFT guidelines recommend clear, comprehensive, and preferably typed documentation for all procedures (total score 32). This audit assessed the quality of cholecystectomy operation notes against these standards, comparing biliary versus non-biliary surgeons. Method This multicentre retrospective cohort study included consecutive adult patients who underwent elective or emergency cholecystectomy across three hospitals between August 2023 and July 2024. Cases were grouped based on whether the operating surgeon was classified as biliary or non-biliary specialist. Operation notes were audited against GIRFT guideline criteria, and results were compared between the two groups. Results Of 564 patients, 405 (71.8%) were female, with a median age of 53 years. Biliary surgeons performed 125 (22.2%) procedures, while non-biliary surgeons performed 439 (77.8%). Emergency cholecystectomies were more frequently performed by biliary surgeons (44.8% vs 35.1%, p=0.047), who also had a higher rate of typed operation notes (94.4% vs 59.0%, p<0.001). The median GIRFT score was significantly higher among biliary surgeons (29 [IQR 27–31]) compared to non-biliary surgeons (19 [IQR 16–21]), p<0.001. Notably, none of the non-biliary surgeons achieved a perfect score (32/32). Conclusions This audit highlights a clear and concerning gap in compliance with GIRFT standards among non-biliary surgeons. The marked disparity in operative note quality carries important implications for patient safety, medico-legal accountability, and clinical continuity. To address this, the implementation of typed, standardised operation notes should be mandated, with targeted interventions to ensure adherence to national documentation standards.