A thorough note: Does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines?

Abstract

Introduction: Operation notes provide an insight into the operative process and stand as a legal document of a surgical procedure occurring. Maintaining accurate, complete and legible notes is fundamental for post-operative patient care and medico-legal purposes. This study aimed at comparing the quality of laparoscopic appendicectomy operation notes prior-to and after the introduction of a procedure-specific proforma consistent with the Royal College of Surgeons of England (RCSEng) guidelines, 2014. Methods: Nineteen parameters based on the RCSEng ‘Good Surgical Practice’ 2014 guidelines were used to audit laparoscopic appendicectomy operation notes. The study consisted of a retrospective audit of 43 consecutive laparoscopic appendicectomy operation notes and a prospective audit of 57 consecutive operation notes following the introduction of a procedure-specific proforma (existing in both hard copy and electronic versions) for laparoscopic appendicectomy. We assessed: (i) the overall compliance with the RCSEng guidelines, (ii) whether each parameter of RCSEng guidelines recommendations were clearly recorded in the operation notes, and (iii) legibility of operation notes. Statistical analysis for difference between the two groups was performed using the independent sample t-test. Results: After introduction of a procedure-specific profroma for laparoscopic appendicectomy, average compliance with RCSEng guidelines increased from 66% retrospectively to 94% prospectively (p < 0.00001). In 8 of the 19 parameters assessed there was significant improvement in adherence to guidelines. Discussion: The implementation of a procedure-specific operation significantly increased compliance with RCSEng guidelines. Such proformas may help reduce variability and standardise operation notes for the same procedure and improve post-operative care. Highlights:

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

“…The specific headings added into the orthopaedic typed notes allowed for better documentation in the operation notes. These findings correlate well with the findings of Abbas, et al (2016) who used specific proformas for laparoscopic appendicectomies to show a significant improvement in operation note compliance with the RCS guidelines [8]. They also showed an improvement in overall legibility when using procedure specific proformas.…”

“…Typed and handwritten proformas that are specific to specific surgeries or to surgical specialties have been shown to increase compliance with the RCS guidelines [5,6-7]. They may also assist in training surgical trainees and act as a teaching aid for procedures [8]. …”

A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery

“…Hussien et al [21] 2015 After introducing a standardized printed proforma, an overall significant improvement in the studied parameters was noticed (p\.0134) [13,20,24,27]. Necessary reporting items concerning transurethral bladder tumor resection significantly improved from .5 to 27% when surgeons were directed to consult a 10-item checklist before surgery and while entering the operative report (p\.001) [14].…”

Does the development and implementation of a procedure-specific proforma for skin lesion surgery improve quality of operation notes?

“…Specialities such as orthopaedics and general surgery have already demonstrated the benefits of procedure-specific proformas in their practice. 9 , 10 …”