EP.TU.2Standards in Operation notes

Abstract

Guidelines exist for operation notes from the Royal College of Surgeons of England but compliance has been shown to be variable. Aim The authors performed an audit of compliance with RCS standards in a colorectal department. Methods Thirty random operation notes were selected from a conserved pool. Their compliance was recorded against RCS good surgical practise record keeping and also looked particularly at fistula surgery and there documentation. Result Compliance was found to be poor and recommendations were put in place and the following was re audited. Conclusion As some specialities are developing operation note standards specific to individual procedures, the findings are compared with previous similar published work.