101Smart Ltd.

Are post-operative instructions clearly explained in operation notes? - Developing the Abscess Pathway as Day Case Standardized Pathway

Sadaf Khalid
Barnet General Hospital, London, United Kingdom


Introduction: “Good Surgical Practice” guidance states that operation notes must include “detailed postoperative care instructions” to facilitate continuity of care by clinicians, alongside the patient themselves. This is especially important for abscess incision and drainage (I&D); most common day-case procedure where patients are left with complex, inaccessible wounds requiring frequent dressings. This study aimed to investigate and improve the compliance of post-operative documentation for I&D procedures as standardized day case pathway.

Methods: Retrospective analysis of 100 consecutive abscess I&D procedures performed at a district general hospital between August–November 2022. The operation note for each procedure was screened for post-operative guidance on antibiotic use, analgesia, dressing management, showering, returning to daily activates and follow up.

Results: On average, 55-62 I&Ds were documented each month. 38 operation-notes did not clarify antibiotic choice/duration. Guidance on analgesia was missing from 27 operation-notes; 12 patients reported analgesia-related constipation without laxatives prescribed. Showering and dressing management was excluded from 53% and 19% of notes respectively. 62% failed to provide advice on the first dressing change,Aquacell was not prescribed in 68%.Information on returning to daily activities was only included in 6 notes. Follow-up was not mentioned in 67% of cases.

Conclusions: Documentation of post-operative instruction for abscess I&D is inconsistent, increasing risks of patient anxiety, pain, infection, and re-presentation to hospital. Data collected was used to design the ‘Abscess Pathway’ to standardise information provided to patients in the pre-/post-operative period in the form of leaflets and personalised proformas.