The first cycle of an audit assessing the quality of documentation of emergency laparoscopic appendicectomies at Birmingham Heartlands Hospital, a District General Hospital

Abstract Background Laparoscopic appendicectomy is a common general surgical procedure. Poor documentation can a) result in misunderstandings between healthcare workers looking after patients and b) limit fair investigation of incidents. The Get It Right First Time (GIRFT) guidance was produced to advise on the information that should be available in patient records to reduce risk of both of the above. Aims and objectives To assess how well laparoscopic appendicectomies are documented in accordance with the GIRFT criteria. To then develop interventions to improve documentation and ultimately improve communication with other healthcare workers and allow defence of good medical practice. Methods Three people collected data on 100 laparoscopic appendicectomies that took place in 2022-2023 at Heartlands Hospital. Data was collected based on the 34 GIRFT recommendations and the sources were: electronic patient notes (adults); scanned patient notes (children); electronic operation notes (all); and theatre logbooks. It was then analysed and grouped into factors that were documented well (>75% of the cases), moderately well (>50% but £75%), poorly (>25% but £50%) or very poorly (£25%). Results Factors that that were documented well (23%) included use of a sterile bag for appendix removal (83%), details of closure (96%), and instructions for post-operative antibiotics (88%) and recovery (97%). Those documented moderately well (19%) included port location and size (70%) and achievement of haemostasis (62%). Those documented poorly (23%) included whether ports were inserted under direct vision (38%) and whether any residual appendix was left behind (39%). Those documented very poorly (36%) included sending a sample to histology and grade of doctors. Several of these were documented primarily in paper records that are not scanned - hence not readily accessible). Conclusions While there are several aspects of documentation which we are currently doing well, there is still much scope to improve documentation as a whole. The current format of the operation note itself limits the information which can be communicated. This in combination with the documentation of some important information on paper – which is largely inaccessible outside of theatre or once a patient has been discharged – produces unnecessary ambiguity. Discussion is ongoing with electronic records teams to alter the operation note format to improve documentation quality. These findings will be discussed at a departmental audit meeting to specify changes before re-auditing.