A CLINICAL AUDIT OF GENERAL SURGERY OPERATIVE NOTE DOCUMENTATION AND IMPLEMENTATION OF A STANDARDIZED TEMPLATE. drhritiksavla@gmail.com

PW07-08

A CLINICAL AUDIT OF GENERAL SURGERY OPERATIVE NOTE DOCUMENTATION AND IMPLEMENTATION OF A STANDARDIZED TEMPLATE.

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India

Oral or Poster

Operative notes serve as an essential component of surgical documentation, ensuring patient safety, continuity of care, and medico-legal credibility. The Royal College of Surgeons (RCS) provides guidelines for good surgical practice, but variations in documentation due to the absence of a standardized template often result in incomplete or illegible notes. This audit aims to assess compliance with RCS guidelines and implement a structured operative note template to improve quality and consistency of the operative notes.

A prospective audit was conducted in the General Surgery Unit 2 of a tertiary care center in Mumbai over 2 months. In the first cycle, operative notes were evaluated based on RCS Good Surgical Practice guidelines. After identifying deficiencies, an intervention in the form of a standardized operative note template was introduced. In the second cycle, post-intervention data were collected and analyzed to assess improvements in documentation quality.

Preliminary findings suggest significant variations in documentation, particularly in completeness, legibility, and adherence to key RCS parameters. Implementation of a structured template is expected to standardize documentation, improving clarity, accuracy, and medico-legal reliability.

This audit highlights the need for standardized surgical documentation. The adoption of a structured operative note template has the potential to enhance patient care, streamline workflow, and ensure compliance with best practices in surgical documentation. Further studies are warranted to assess long-term impact and sustainability.