369 Do We Need to Standardise the Neurosurgery Post-Op Note: A QI Project

Abstract

Aim Accurate, informative, and consistent documentation in the postoperative period is an essential aspect enabling effective and safe communication between healthcare professionals. Limited documentation can increase the risk of errors and suboptimal care. The Royal College of Surgeons (RCS) identified 18 criteria for operation note documentation for ‘Good Surgical Practice’, enabling continuity of care. Currently, the structure and information documented in a tertiary neurosurgical department varied. The aim of this quality improvement project was to improve the documentation in the department using a proposed proforma. Method A proforma was identified using the RCS guidelines and distributed via email. Operation notes of all patients undergoing neurosurgical procedures were compared against RCS guidelines from November 1st – November 30th, 2020, pre-proforma introduction. Operation notes were then re-audited from July 1st – July 31st post-proforma introduction. Results 66 operations were identified in the pre-proforma group, and 49 in the post-proforma group. Date, time, details of tissue alteration, operative findings, incision, prosthesis identification, antibiotic use and signature were well documented in both pre and post proforma introduction (>90%). In the reaudited group there was an improvement in documentation of anaesthetist (37 vs 24%), complications (78 vs 35%), extra procedures (18 vs 2%), blood loss (22 vs 12%), and a small decrease in the documentation of DVT prophylaxis (59 vs 53%). Conclusions A structured proforma is useful for enhancing communication in the post-operative period. We aim to create a standardised template in the trust's note-taking system to standardise the documentation process and provide further training on the importance of documentation.