A thorough note: Does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines?

• A procedure-specific proforma significantly improved compliance with RCSE guidance.
• Procedure-specific proformas have been used with success in orthopaedic surgery.
• In general surgery, the use of procedure-specific proformas is less widespread.
• Use of such proformas will allow robust medico-legal documents to be produced.
• They may also standardise operation notes and help develop electronic based systems.

IntroductionOperation notes provide an insight into the operative process and stand as a legal document of a surgical procedure occurring. Maintaining accurate, complete and legible notes is fundamental for post-operative patient care and medico-legal purposes. This study aimed at comparing the quality of laparoscopic appendicectomy operation notes prior-to and after the introduction of a procedure-specific proforma consistent with the Royal College of Surgeons of England (RCSEng) guidelines, 2014.MethodsNineteen parameters based on the RCSEng ‘Good Surgical Practice’ 2014 guidelines were used to audit laparoscopic appendicectomy operation notes. The study consisted of a retrospective audit of 43 consecutive laparoscopic appendicectomy operation notes and a prospective audit of 57 consecutive operation notes following the introduction of a procedure-specific proforma (existing in both hard copy and electronic versions) for laparoscopic appendicectomy.We assessed: (i) the overall compliance with the RCSEng guidelines, (ii) whether each parameter of RCSEng guidelines recommendations were clearly recorded in the operation notes, and (iii) legibility of operation notes. Statistical analysis for difference between the two groups was performed using the independent sample t-test.ResultsAfter introduction of a procedure-specific profroma for laparoscopic appendicectomy, average compliance with RCSEng guidelines increased from 66% retrospectively to 94% prospectively (p < 0.00001). In 8 of the 19 parameters assessed there was significant improvement in adherence to guidelines.DiscussionThe implementation of a procedure-specific operation significantly increased compliance with RCSEng guidelines. Such proformas may help reduce variability and standardise operation notes for the same procedure and improve post-operative care.