Wen Wei Lim
In modern healthcare, proficient record-keeping is essential, particularly when dealing with issues related to medical malpractice. Research has consistently shown that medical and operative notes often fall short in terms of accuracy, completeness, validity, legibility, reliability, and precision, highlighting persistent shortcomings in record-keeping practices. To improve the quality of operative notes, the Royal College of Surgeons (RCS) introduced official guidelines in 2014. Adherence to these guidelines within our institution remains uncertain.
Methods
A retrospective analysis was conducted on 99 consecutive operative notes from elective upper GI procedures between December 2024 and February 2025. Data were collected from the electronic patient record system and assessed against RCS guidelines using Microsoft Excel. Following an initial audit and implementation of interventions (primarily email reminders to staff), presentations at governance meetings, a re-audit was performed in April 2025 on a matching sample.
Results
Post-intervention improvements were observed across nearly all documentation domains. For example, documentation of date/time of surgery improved from 84.8% to 97%, and estimated blood loss from 97% to 100%. Documentation of antibiotic prophylaxis rose from 75.8% to 82.8%. While full compliance (>90%) was not achieved across all domains, improvements were consistent.
Conclusions
This audit highlights persistent documentation gaps but also demonstrates the impact of simple interventions on adherence to national standards. Ongoing efforts aim to ensure sustained improvement, supporting the broader goals of safety and quality in day surgery practice.
Authors
Wen Wei Lim
Hull University Teaching Hospitals Trust, Hull, United Kingdom