AB150. SOH23ABS_199. The implication of procedure-specific operative proforma: improving the quality of operative notes for laparoscopic cholecystectomy, surgical audit report in St. Luke’s General Hospital Kilkenny

Background: Operative notes are the fundamental way to document procedural details, yet essential details are frequently missing. To improve the operative documentation, the use of procedure-specific operative proforma is recommended. Laparoscopic cholecystectomy is the most performed minimally invasive surgical procedure with over 1.1 million procedures per annum in the United States alone and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible.

Methods: This is a retrospective cross-sectional study in which we compared the operative notes written for laparoscopic cholecystectomy from 1st January 2021 till 31st December 2021 against the pre-designed operative proforma which includes all the recommendations from both Royal college of surgeons (RCS) and Dutch society of surgeons (DSS) guidelines. Data were retrieved using surgical audit software and a total of 69 operative notes were retrieved. All notes were compared by two reviewers independently and then any uncertainty was discussed among each other. All ratings were doubly checked by a third reviewer. Data were analyzed using statistical package for the social sciences (SPSS) 23, frequencies were obtained and formulated in Bar charts using Microsoft word.

Results: Many Important information were found to be missing in the surgical notes. Only 14.5% notes contain information about pre-op antibiotics, 20.3% lack number of ports, 36.2% did not mention the gallbladder condition, around 27.5% lack the documentation regarding the establishment of critical view of safety. Similarly, 23.2% did not contain information regarding dissection of gall bladder and bile spillage. removal of ports under vision was only mentioned in 29.4% of the notes.

Conclusions: Implication of procedure specific proforma is suggested for adequate documentation in any circumstances which can prevent future litigations and maintain the quality of care.

Keywords: Laparoscopic cholecystectomy; operative proforma; Royal College of Surgeons guidelines; Dutch Society of Surgeons guidelines; comparison with standards