Assessing Adherence to Royal College of Surgeons Guidelines: A Closed-Loop Audit of Operation Notes in a Tertiary Healthcare Unit.

Introduction Accurate, comprehensive, and legible operation notes are essential for maintaining patient records, supporting healthcare professionals, and facilitating research. The study focused on adherence to Royal College of Surgeons (RCS) guidelines established in 2008. Despite the guidelines, poor documentation practices have been reported globally. This audit seeks to address this issue and enhance documentation quality. Methodology The audit evaluated 19 parameters as defined in the 2014 RCS operative note guidelines. Data collection occurred during the initial cycle, spanning from March to April 2023, encompassing all surgical procedures at Hayatabad Medical Complex (HMC). Subsequently, a re-audit took place in July 2023 to gauge enhancements following a survey and educational intervention that took place in June 2023. The process included the formation of an audit team, securing ethical approval, and implementing a comprehensive methodology for data collection and analysis. The study spanned two data collection cycles to comprehensively assess improvements. Results Comparing initial and re-audit cycles (n = 390 and n = 108, respectively), improvements were observed in several documentation aspects. Parameters such as surgery date, elective/emergency classification, and names of key personnel showed significant enhancement. Notable improvements were also seen in the recording of operative details, complications, extra procedures, and post-operative care instructions. In our department, an educational survey was conducted to gain insights into compliance rates. This survey underscored the significance of adhering to RCS guidelines, identified the factors influencing adherence, and proposed strategies for improvement. Conclusion The audit affirmed the significance of adhering to RCS guidelines for operation note documentation. The study demonstrated improvements in documentation practices, emphasising the importance of accurate records for patient care, research, and ethical standards. The findings validate RCS guidelines as a tool for the identification of defects in documentation and thus as a guide that highlights where improvements are necessary. Addressing challenges identified in this audit can drive the department towards becoming a model for RCS guideline adherence and showcasing high-quality surgical documentation and patient-centred care.