781 An Overview of Operative Notes in the Vascular Surgical Unit in Northern Ireland

Aim

This audit aims to assess the conformity of operative notes to the guidelines established by the Royal College of Surgeons England (RCSEng).

Method

We prospectively collected and analysed the date over a two-week period before we introduced the intervention. We created a poster featuring the guidelines and placed it in the vascular operating theatres. We also introduced an electronic operative note system in vascular surgery. The reaudit commenced two weeks after the intervention.

Result: All operative notes contained the date and time, names of surgeons, details of the operative procedure, descriptions of tissue removed, identification of prosthetics, and the surgeon's signature. Some areas saw significant improvement with the intervention, such as incision (26% to 89%), operative diagnosis (58% to 93%), closure technique (92% to 100%), and post-operative instructions (83% to 93%). However, there was a lack of documentation on DVT prophylaxis and antibiotic prophylaxis in both loops, resulting in a decrease from 63% to 50% for DVT prophylaxis and from 38% to 14% for antibiotic prophylaxis. Only two electronic operative notes were recorded in the second loop.

Conclusions

Some areas showed improvement, but not all achieved full compliance. The majority of vascular surgeons continued to utilize handwritten operative notes due to logistical and technological challenges. It is recommended that a future re-audit be conducted over a longer period of time, during which a greater number of cases should be reviewed.