Auditing the quality of operation notes in colorectal surgery at University Hospitals of North Midlands

Abstract Introduction Constructing an accurate and comprehensive operation note is an important process in a patients’ journey as it should provide sufficient information to allow continuity of care by other healthcare professionals. We performed an audit of operation notes in colorectal surgery to assess whether they meet the standards as described by the Royal College of Surgeons. Method Retrospective data was collected over a period of 10 months to include all major elective colorectal operations. Operation notes were scrutinised for all 17 relevant data points as described in Good Surgical Practice. The electronic patient system at our trust populates the operation note with date/time, surgeons and anaesthetist. Results There were a total of 232 major colorectal procedures performed between May 2020 and March 2021. 12 data points were adhered to 100%. Estimated blood loss was only documented in 18.1% (n=42) of operation notes. Pre-operative DVT prophylaxis was documented in 6% (n=14) of operation notes. Details of tissue removed were not documented in 3% (n=7) of operation notes. Antibiotic prophylaxis was not documented in 1.7% (n=4). Theatre anaesthetist was not documented in 1.3% (n=3) of operation notes. Conclusions Operation notes in electively colorectal surgery are not meeting the standard as set out in Good Surgical Practice. There is a potential for change by adding drop down sections on the electronic operation note to ensure all operation notes meet the standards and are uniform. These changes will be trialled and the data re-audited in the near future.