1088 The Quality of Information Recorded in Neurosurgical Operation Notes: A Closed Loop Audit

Abstract

Operation notes are critically important documents which serve as record for significant events in the lives of patients. They serve multiple functions, but chiefly to help guide peri-operative management. Surgeons must keep records that are accurate, thorough, and readable. This is fundamental part of the GMC’s Good Medical Practice as well as the Royal College of Surgeons of England Good Surgical Practice guidelines which lays out 18 various parameters for what should be included in an operation note. This retrospective audit aimed to evaluate the compliance of neurosurgical operation notes with the Royal College of Surgeons guidelines, identifying areas for improvement. All neurosurgical procedures between October 1 and October 31, 2023, at a Major Trauma Centre in the West Midlands were retrospectively audited. Two independent reviewers used a standardized proforma in Microsoft Excel for data extraction, comparing compliance. 91 operation records were examined and found high compliance (100%) in key fields: date, surgeon's name, assistant's name, operative procedure, operative diagnosis, and signature. Negligible compliance was found in identification of prosthesis (0%), estimated blood loss (1%), extra procedures (1%), elective/emergency classification (1%), time (4%), and problems/complications (19.8%). Notably, detailed post-op instructions were lacking in over 1 in 3 operation notes, with 19.7% omitting DVT prophylaxis, and 20% neglecting clip/suture removal instructions. While certain aspects showed exemplary compliance, critical deficiencies were identified, particularly in post-operative instructions. A template proforma for post op instructions is required in addition to more targeted guidelines for operation notes within neurosurgery.