TPT 6.09 Enhancing Patient Safety through Standardised Operative Note Documentation- A Closed-Loop Audit on Laparoscopic Appendicectomy Operative Note

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ID: 323878
2026
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Abstract
Abstract Aim Accurate operative note documentation is essential for patient safety, effective postoperative care, and medico-legal protection. National guidance from GIRFT and the Royal College of Surgeons of England emphasises the importance of comprehensive operative documentation. This closed-loop audit aims to evaluate the impact of a procedure-specific operative note for laparoscopic appendicectomy and education following the first-cycle audit, which identified significant deficiencies in the documentation. Methods A retrospective closed-loop audit was conducted at a District General Hospital. In first cycle, laparoscopic appendicectomy operative notes (n=56; February–April 2025) were assessed against GIRFT standards. Interventions included distribution of a standardised procedure-specific operative note template, targeted teaching, and workflow reinforcement. A re-audit was performed (n=46; July–October 2025) to compare compliance across standardised templates, handwritten/self-designed notes, and first-cycle results. Results Following the intervention, significant improvement was noted in the documentation of laparoscopic appendicectomy operative notes. 27 criteria were assessed in operative notes, and comprehensive documentation of all 27 measured criteria (100% in 22 and >95% in 5 criteria) was achieved using a standard operative note template. In second cycle, 85% (n=23/27) of standardised template operative notes achieved 100% compliance, compared with 7% (4/56) of operative notes in the first cycle. None of handwritten or self-made operative notes in the second cycle achieved full compliance. Conclusion This study demonstrated that implementing a standardised, procedure-specific operative note template with targeted teaching significantly improved documentation quality, enhancing patient safety. These interventions, grounded in human factors principles, are easily reproducible and applicable to other surgical procedures.
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Authors Dilip Kumar Pulluru Rajasekhar, Noureldine Nagui, Rahi Karmarkar, Haseeb Jarral, Trevor Lopez, Wadah Abdelazim Ahmed Ali
Journal the british journal of surgery
Year 2026
DOI
10.1093/bjs/znag087.232
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