An electronic template improves operation notes in General Surgery.

Background: Surgical operation notes are crucial in maintaining patient safety and have medico-legal importance. We aimed to quantitatively assess and improve the content of operative notes in General Surgery at a district general hospital in London. Material and methods: 100 operation notes written between 26th July and 24th October 2022 were analysed retrospectively. Operation notes were awarded a point for each of the key details recommended by the Royal College of Surgeons (RCS) that they included. A new operative template, pre-populated with headings based on the RCS guidelines, was made available to the surgical team. A further 100 operation notes between 1st December 2022 and 28th January 2023 were assessed using the same scoring system as in Cycle 1. Results: Mean operation note score significantly increased from 75.7% in Cycle 1 to 81.0% in Cycle 2 (P = 0.021). In Cycle 2, the 33% of operation notes used the new template scored significantly higher than those that did not (98.5% vs 68.2%, P < 0.0001). Conclusion: Operation note quality can be significantly improved using a template based on RCS guidelines. Templates are a cost-effective way to promote safer postoperative care and reduce the risk of medico-legal action against the operating team. Brief Abstract: We assessed the quality of surgical operation notes at a district general hospital in London using criteria recommended by the Royal College of Surgeons, before and after introducing an electronic operation note template. We observed a significant improvement in operation note quality after implementing the template, suggesting that this is a cost-effective way to promote safer postoperative care and reduce the risk of medico-legal action against the operating team. [ABSTRACT FROM AUTHOR]