POST-OP: A Strategy to Improve Clinical Documentation in the Early Postoperative Period

To construct and pilot an educational tool to improve the quality of postoperative documentation at Mayo University Hospital.

Retrospective data were collected from 100 consecutive patients treated surgically during October to November 2016. The first written ward based note following surgery was analyzed against RCS quality standards outlined in "Good Surgical Practice." An educational tool was then constructed to improve postoperative documentation. The mnemonic created was POST-OP-physiotherapy/mobilization, operative diagnosis, sepsis, thromboprophylaxis, oral intake/fluid balance, and pain. A second audit cycle involving 103 patients was carried out prospectively in March 2017.

Mayo University Hospital, a 330 bed teaching hospital affiliated with the National University of Ireland, Galway.

All patients who had undergone either an elective or an emergency general surgery procedure over two 5-week periods.

Comparing the 2 study periods, significant improvements in the quality of postoperative surgical documentation was observed. All standards improved including patient identification (17.8% vs 78.1%, p < 0.001) and name of note maker (54.7% vs 86.2%, p < 0.001). There was also improvement in the documentation of antibiotic use (23.8% vs 75.8%, p > 0.001), thromboprophylaxis (7.1% vs 75.8%, p < 0.001), analgesia (36.9% vs 74.7%, p < 0.001), operative diagnosis (66.6% vs 91.9%, p < 0.001), and mobilization (23.6% vs 78.1%, p < 0.001) following the introduction of the POST-OP tool.

The design and introduction of the POST-OP education tool helped to significantly improve documentation and educate surgical residents on the essential components of postoperative care. The above data suggest that this effective mnemonic can improve the quality of postoperative documentation for surgical patients.