The impact of an operative note proforma at a paediatric surgical centre

Rationale, aims and objectives With expectations for standardization and evidence‐based practice, the R oyal C ollege of S urgeons ( RCS ) published the ‘ G ood S urgical P ractice’ in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico‐legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma. Methods All general surgery and urology admissions during J uly 2011 and A ugust 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in F ebruary 2012. Results were compared and statistically analysed using two‐tailed F isher's exact test, with B onferroni correction where appropriate ( SPSS 20.0, IBM SPSS S tatistics, A rmonk, NY , USA ). Results There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistant's name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetist's name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% ( P  < 0.05). Subgroup analysis in the latter cohort shows most of these effects to be related to the use of the proforma rather than education alone ( P  < 0.05). Quality of documentation was better by consultants versus trainees in 2 of 23 criteria ( P  < 0.05). Conclusion We have demonstrated a simple and cost‐effective way of improving the quality of operative documentation, in line with guidelines set out by the RCS , in a climate of increasing economic austerity.