Assessing the Adherence of Operative Notes for Laparoscopic Appendectomy with the Royal College of Surgeons...

Objective: To determine the frequency of adherence of laparoscopic appendectomy operative notes with the Royal College of Surgeons (RCS) guidelines at the tertiary care centre.  Study Design: A clinical audit report.

The Aga Khan University Hospital, Karachi between January and June 2018.

Operative notes of laparoscopic appendectomy, written by residents of general surgery from trainee levels R1 to R5 during the study period, were included in the study. Each component from RCS guidelines, was assessed. The response to every question in proforma was marked either as Y=Yes or N=No. Overall score of more than 70% was chosen arbitrarily as a qualifying standard for an adequate operative note. Data were analysed by using SPSS (version 21). A p-value of <0.05 was considered significant.

A total of 74 operative notes relating to laparoscopic appendectomy were reviewed during the study period. Most of these, i.e. 46% notes, were written by year one residents; 47.1% operative notes showed adequacy of practice in concordance with RCS guidelines. The most lacking component in operative notes was mentioning of the operative time, port sites, intraoperative complications and details of specimen removed. Stratified analysis of operative notes did not reveal any association between age, gender and level of training of residents to affect the adequacy of operative note documentation.    Conclusion: Only a quarter of the studied documentation fulfilled the criteria for adequacy of practice. Residents need to be educated and familiarised with these guidelines to improve documentation of operative procedures. Strategies need to be formulated and tested to improve the performance.           Key Words: Operative notes, Good medical practice, Acute appendicitis, Laparoscopic appendectomy, RCS guidelines.