288 Re-Audited QIP on Accuracy of Documentation in the Surgical Notes and Discharge Letter
| Autor: | BB Karki, J Wolff, A Tsao, M Basamh, F Runau |
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| Rok vydání: | 2022 |
| Předmět: | |
| Zdroj: | British Journal of Surgery. 109 |
| ISSN: | 1365-2168 0007-1323 |
| DOI: | 10.1093/bjs/znac269.249 |
| Popis: | Aim To identify and review the discrepancy between the documentation in the surgical operation notes and discharge summaries. To evaluate the surgical operation notes and assess its compliance with the RCS standard. Method Prospective audit of 64 General Surgery operation notes and their respective discharge letters was carried out in two cycles from March- June 2021. Royal College of Surgeons England Good Surgical Practise, 2014 was used to audit the general surgery notes. Teaching sessions were carried out after the first cycle for the use of Electronic Operation Notes. Furthermore, comparison of this audit results with the different trust following Electronic Operation notes were carried out. Results Operation notes and discharge letters were reviewed on variables like date of procedure, quality of performa based on RCSEng guidelines. There was 50% increase in the use of Typed Operation Notes in the second cycle which showed a significant decrease (almost 50%) in the mentioning of incorrect operation dates. 65% of the handwritten notes were not comprehensive enough or legible. However, Electronic operative note had significant adherence to the RCS guideline. When these data were compared to the other trust using Electronic Operation Notes all the highlighted issues were found in a negligible ration. Conclusions As the data suggests that handwritten Operation Notes were not comprehensive and legible hence replacing these with the electronic operation notes would be best practice. Fully compliant electronic operation notes, reducing in variability by opting single and procedure specific Performa will help to mitigate the issues highlighted. |
| Databáze: | OpenAIRE |
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