A CLOSED-LOOP CLINICAL AUDIT ON COMPLIANCE WITH ROYAL COLLEGE OF SURGEONS GOOD SURGICAL PRACTICE IN OPERATIVE DOCUMENTATION: A QUALITY IMPROVEMENT STUDY

OBJECTIVES This audit aimed to evaluate compliance with Cesarean section documentation standards and to assess the effectiveness of a standardized pro forma with focused training. METHODOLOGY This audit was conducted as a pre- and post-interventional audit from February 10, 2025, to July 10, 2025, in the obstetrics department of Suleman Roshan Medical College Hospital. Using a 17-item checklist based on RCSEng Good Surgical Practice and departmental protocol, we analyzed 120 operative notes before and after implementing a standardized documentation template and operative team education. Compliance rates were calculated as percentages. Statistical comparisons were performed using the McNemar test; p-values <0.001 indicated signifcance. RESULTS The initiative signifcantly improved documentation (p<0.001). Documentation of complications increased from 10% to 99%, DVT prophylaxis recording, when applicable, rose from 0% to 100%, and details of operative findings improved from 55% to 99%. Overall, 14 of the 17 audited parameters were documented in over 95% of cases. The audit also encouraged a departmental culture that emphasizes documentation for patient safety rather than merely as an administrative duty. CONCLUSION The use of a structured pro forma, combined with training, enhances the completeness and quality of operative notes. This approach not only saves time but also helps ensure that crucial details are not overlooked. KEYWORDS: Surgical Audit, Operative Documentation, Cesarean Section, Quality Improvement