Improving Operative Note Documentation in Vascular Surgery: A Two-Cycle Closed-Loop Audit Following Introduction of...

To evaluate completeness of operative note documentation in a vascular surgery service and to assess whether introduction of standardized procedure-specific templates was associated with improved documentation in a repeat audit cycle.

We conducted a single-center two-cycle closed-loop audit within a UK vascular surgery department. In cycle 1, 63 consecutive operative notes from May 2024 were retrospectively reviewed against predefined documentation standards derived from Royal College of Surgeons guidance. Following identification of recurrent omissions, standardized procedure-specific templates were collaboratively developed, disseminated, and introduced at a departmental governance meeting. In cycle 2, 72 consecutive operative notes from March 2025 were reviewed using the same data collection framework. The primary process measures were documentation rates for 4 safety-critical fields: indication for surgery, estimated blood loss, distal pulse status, and postoperative plan. Between-cycle differences were compared using Fisher's exact test and expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

Baseline documentation was incomplete across all 4 variables. Following template introduction, statistically significant improvements were observed for indication for surgery (43.2%-79.5%; OR 5.07, 95% CI 2.38-10.80; P < 0.0001) and distal pulse status (19.6%-65.4%; OR 7.99, 95% CI 3.61-17.68; P < 0.0001). No statistically significant improvement was observed for estimated blood loss (16.3%-19.2%; OR 1.28, 95% CI 0.52-3.12; P = 0.66) or postoperative plan (39.1%-44.9%; OR 1.22, 95% CI 0.61-2.42; P = 0.60).

Standardized procedure-specific templates were associated with substantial, statistically significant improvements in 2 documentation domains. The absence of equivalent improvement in blood loss and postoperative plan recording, confirmed by formal hypothesis testing, indicates that these variables require distinct intervention strategies beyond structured prompting alone. This closed-loop audit supports continued template refinement, targeted behavioral and systems-level interventions, and further re-audit.