Emergency General Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK.
Chelsea and Westminster NHS Foundation Trust, London, UK.
Ir J Med Sci. 2022 Apr;191(2):825-830. doi: 10.1007/s11845-021-02567-6. Epub 2021 Mar 13.
Appendicitis is the most common abdominal emergency in England accounting for 40,000 admissions per year. The Good Surgical Practice guideline by Royal College of Surgeons England (RCSEng) defines criteria detailing what constitutes a safe and comprehensive operation note. High-quality operation notes enable continuity of care and safe post-operative management.
(1) Assess whether laparoscopic appendicectomy operation notes are adherent to RCSEng criteria. (2) Implement an operation note proforma to improve adherence. (3) Re-audit to assess effectiveness of operation note proforma.
A retrospective audit was performed measuring compliance of laparoscopic appendicectomy notes to RCSEng criteria over a 4-month period at a central London tertiary care centre. A laparoscopic appendicectomy operation note proforma was designed and implemented. Compliance to RCSEng criteria was then re-audited against RCSEng criteria, and statistical analysis performed to assess the significance of changes to compliance.
The average compliance with the RCSEng guidelines after the first cycle retrospectively was 56.1%. The average compliance after implementation of the proforma was 98.2%, with above 80% of operation notes satisfying all RSCEng criteria. This was a significant 42.1% (p < 0.0001) increase in average compliance. The implementation of the proforma reduced the amount of hand-written information, saving time and improving legibility of the operation notes.
The implementation of an operation note proforma has the ability to significantly improve operation note quality. This simple and effective intervention to improve operation note quality has the potential to improve post-operative safety and continuity of care post laparoscopic appendicectomy.
在英国，阑尾炎是最常见的腹部急症，每年有 4 万例入院。英国皇家外科学院（RCSEng）的《良好手术实践指南》定义了详细说明构成安全和全面手术记录的标准。高质量的手术记录能够实现护理的连续性和安全的术后管理。
（1）评估腹腔镜阑尾切除术手术记录是否符合 RCSEng 标准。（2）实施手术记录表格以提高依从性。（3）重新审核以评估手术记录表格的效果。
在伦敦市中心的三级护理中心进行了为期 4 个月的回顾性审核，以衡量腹腔镜阑尾切除术记录符合 RCSEng 标准的情况。设计并实施了腹腔镜阑尾切除术手术记录表格。然后根据 RCSEng 标准重新审核符合 RCSEng 标准的情况，并进行统计分析以评估对符合率的影响。
第一个周期的 RCSEng 指南平均符合率为 56.1%。实施表格后，平均符合率为 98.2%，超过 80%的手术记录满足所有 RSCEng 标准。这是平均符合率显著提高了 42.1%（p<0.0001）。表格的实施减少了手写信息的数量，节省了时间并提高了手术记录的可读性。
实施手术记录表格能够显著提高手术记录的质量。这种简单有效的干预措施可以提高术后安全性和腹腔镜阑尾切除术后的护理连续性。
