Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines
Sharukh Zuberi1
, Yusuf Mustaq1, Ali Ijaz2, Samyukta Sundar3, Zahra Mohamedali4, Krashna Patel1, Janso Joseph1, Roy Gurprashad1
1Clinic of General Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom
2Clinic of Otolaryngology, Bradford Royal Infirmary, Bradford, United Kingdom
3Clinic of Maxillofacial Surgery, John Radcliffe Hospital, Oxford, United Kingdom
4Clinic of Gastroenterology, Northwick Park Hospital, London, United Kingdom
Abstract
Objective: Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma.
Material and Methods: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020.
Results: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p< 0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001).
Conclusion: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.
Keywords: Emergency general surgery, operation notes, royal college of surgeons, audit, electronic operation notes
Cite this article as: Zuberi S, Mustaq Y, Ljaz A, Sundar S, Mohamedali Z, Patel K, et al. Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the royal college of surgeons guidelines. Turk J Surg 2024; 40 (1): 11-18.
The authors have received institutional permission to proceed with the study. Approval was provided in a letter uploaded to the Journal’s official system on 21.12.2023.
Externally peer-reviewed.
Concept - ACE, ME, KD; Design - ACE; Supervision - MK; Fundings - All authors; Data Collection and/or Processing - ACE, ÖE, ARP; Analysis and/or Interpretation - ACE, KS; Literature Search - ACE; Writing Manuscript - ACE, MT; Critical Reviews - MK.
The authors have no conflicts of interest to declare.
The authors declared that this study has received no financial support.