TPTh 2.11 Documentation of History Recording of RIF Pain in Adults

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ID: 323970
2026
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Abstract
Abstract Aim Right iliac fossa pain is one of the most common general surgical emergency presentations, and accurate history documentation is essential for safe diagnosis and management. This audit aimed to assess the quality of documentation of history taking in adults presenting with RIF pain at NCIC following the introduction of a standardized RIF pain history sticker from previous cycle. Method A retrospective audit was conducted from 20 May to 20 June 2025. Adult patients (≥18 years) admitted with RIF pain under general surgery were included. Data from 45 patients were collected and recorded on a predefined data collection tool. Documentation was assessed against NCIC guidelines for RIF pain history taking, including pain characteristics, associated gastrointestinal and systemic symptoms, previous episodes, and relevant gynaecological history where applicable. Results were compared with those from the initial audit cycle. Results Of the 45 patients reviewed, 23 were male and 22 female. Overall compliance with effective documentation of RIF pain history improved from 73% in the first audit cycle to 96% following introduction of the RIF pain history sticker. Most key history components, including duration and nature of pain, associated symptoms, and gastrointestinal features, demonstrated near-complete compliance. Documentation standards reached the “high compliance” category. Conclusion The introduction of a standardized RIF pain history sticker significantly improved the quality and completeness of documentation. This demonstrates that simple, structured interventions can enhance adherence to clinical guidelines and improve patient safety. Continued use of standardized clerking tools and recommended to sustain high documentation standards.
Reference Key
openalex_W7172533367 Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Muhammad Umair Butt, Muhammad Ibtahaj Chaudhery, Saira Bibi, J Wayman
Journal the british journal of surgery
Year 2026
DOI
10.1093/bjs/znag087.436
URL
https://doi.org/10.1093/bjs/znag087.436
Keywords Keywords not found

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