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419 A Review of Operative Narrative Documentation Compliance with RCS Guidance for Laparoscopic Cholecystectomies

Year: 2025
Type: article
Study design: Observational Study
Abstract: Aim Operation notes not only ensure continuity of care within the multidisciplinary team but also provide a medicolegal record of a patient's care. The NHS settled £20.4 million in Laparoscopic Cholecystectomy (LC) associated litigation costs over a 15-year period, with poor operative documentation cited to prevent the defence of good clinic practice. In 2022, RCS published guidance for LC operative documentation, and we aimed to review our records against this guidance. Method Computerised hospital records were utilised to identify any patient that underwent an elective day case LC between May – June 2024. Operative notes were scrutinised against RCS recommendations and the inclusion of a Parkland Grading Scale (PGS) was also reviewed. Results 60 patients met the inclusion criteria. Of these 60% had a PGS documented. The frequency of PGS documentation was higher when the operative note was completed by a registrar compared to a consultant, (73% vs. 63%). A subset of patients (n=15) was randomly selected for in depth scrutiny of their operative narrative. Compliance rates in documentation for the following RCS recommendations were as follows:Ports inserted and removed under direct vision - 46.7%Antibiotic administration - 6.7%Comment on bile or stone spillage 6.7%Recording intra-abdominal pressures used - 0%Critical view of safety achieved – 100% Conclusions Our results demonstrate that significant improvements can be made in our LC operative note documentation. We plan to implement a standardised operation note template which incorporates the RCS recommendations and re-audit our performance. We hope this template supports all grades in remaining vigilant with their operative documentation.
DOI: 10.1093/bjs/znaf270.294
Language: English
Subfield: Pharmacy
Open Access status: bronze
OpenAlex ID: W7117450643
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