TH3.5 Completeness of operative reports for rectal cancer surgery. (9th August 2022)

• Record Type: Journal Article
• Authors: Bae, Inmook; Spinks, William; Saravanan, Balakrisanan; Moscalu, Andrei
• Is Part Of: British journal of surgery. Volume 109(2022)Supplement 5
• Publication Date: 2022-08-09
• Subjects: Surgery -- Periodicals; 617.005
• DOI: 10.1093/bjs/znac248.211
• Languages: English
• ISSNs: 0007-1323

Abstract

Abstract: Introduction and Objectives: Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation, which ultimate improves quality of care. We set out to assess whether post-operative reports, made at the JPUH, include the primary components recommended by the National Accreditation Program for Rectal Cancer. The JPUH does not currently use synoptic templates to guide post operative note making. Methods and materials: We retrospectively looked at the post-operative reports for 71 patients who had undergone surgery for rectal cancer from March 2018 to October 2020 at the James Paget University Hospital. These reports were evaluated to establish how many of the primary components were included. Results: Of the 71 reports assessed, none included all 23 components. The areas well documented included the nature of the operation (100%), completeness of resection (93%), the type of reconstruction (85%) and anastomosis testing method (97%). The areas that were poorly documented included en bloc resection (8%), metastectomy (0%), intra-operative complications (0%) and blood transfusion (0%). Overall there was 53% completeness of documentation. Conclusion: Rectal cancer post-operative note making at the JPUH does not meet the standard expected by the NAPRC. Some points were documented well and others were infrequently documented. Plans are in place to introduce accessible templates to guide note making and re-audit will be completed.