Improving Compliance With Operative Note Guidelines Through the Implementation of an Electronic Proforma

Background An operative note (op note) is a vital medical record of remarkable clinical, medico-legal and academic relevance. The Royal College of Surgeons (RCS) has set out a guideline to standardise op notes. This closed-loop audit assessed the compliance of op notes completed in our local hospital against the guidance set by RCS with the view to identify deficiencies and improve practice. Methods A retrospective review of general surgery operative notes was carried out to access their various characteristics against RCS guidance. Two additional parameters were assessed, namely, ‘cadre of the surgeon that completed the op note’ and ‘use of abbreviations’. To improve compliance with RCS guidelines, an electronic proforma (EP) that included all the 18 characteristics listed in good surgical practice was implemented and a re-audit was undertaken six months afterwards. Results A total of 200 op notes were reviewed, 98 during the initial audit cycle and 102 at the re-audit. Seventy-eight per cent (78%) of the op notes were written by trainees. At the initial audit, seven parameters performed poorly, with compliance ranging between 5.1% and 76.5%. The re-audit demonstrated improved adherence to guidelines following the implementation of the EP, as well as a reduction in the use of abbreviations. The overall compliance improved from roughly 80% to >95%. Conclusion A sustainable change was achieved through the implementation of EP with improvement demonstrated in content and structure. The need to provide teaching to trainees who are responsible for writing a vast majority of op notes was identified.