ENHANCING SURGICAL DOCUMENTATION: A CLINICAL AUDIT ON OPERATIVE NOTES COMPLIANCE yukijulius@gmail.com

PE075

ENHANCING SURGICAL DOCUMENTATION: A CLINICAL AUDIT ON OPERATIVE NOTES COMPLIANCE

3

Malaysia

Oral or Poster

This audit, conducted at a secondary care hospital, aimed to evaluate the quality of operative note documentation in reference to the Royal College of Surgeons of England (RCS) guidelines and assess the utilisation of the online theatre-based system.

A retrospective review of operative notes was undertaken across two audit cycles, with an intervention introduced between cycles. The intervention included facilitated online access, consultant induction, dissemination of user guides, and mass communication to surgical teams.

In the first cycle, 70 operative notes were assessed, followed by 66 in the second. Compliance with RCS documentation standards improved significantly from 69% to 96.6% post-intervention. Use of the post-operative template increased from 18.2% to 44.1%, and electronic documentation remained at 60%. The absence of timely online access at staff induction was identified as a major barrier to electronic note access. The audit demonstrated that structured interventions can markedly enhance the quality and completeness of operative notes. This, in turn, will facilitate improved documentation and continuity of care, post-operative management, and medico-legal standards. Key recommendations include ensuring early electronic access for new staff along with a structured induction of user guide, documentation protocols, and ongoing monitoring to maintain high standards.

This quality improvement initiative highlights the critical role of electronic surgical operation notes in maintaining patient safety and clinical efficiency.