703 Elevating Documentation Practices: Examining the Longitudinal Impact of an Electronic Operation Note Proforma in a District General Hospital

Abstract Aim This study aimed to enhance the standard of operation note documentation at a district general hospital, in accordance with the guidelines established by the Royal College of Surgeons of England (RCSEng). A new electronic operation note proforma was developed, implemented, and assessed for both its influence on compliance with guidelines immediately after enactment, and for sustaining affects in the following years. Method A retrospective review of 50 operation notes was conducted between December 2019 and March 2020, and quantitatively compared to RCSEng guidelines. Another 50 notes were then assessed between August 2020 and December 2020, following implementation of a new electronic proforma. An additional 100 operation notes were then analysed between August 2022 and November 2023. Results A total of 200 operation notes were reviewed and each awarded a score out of 19 based on RCSEng guidelines. Implementation of the new proforma showed significant improvement to the average score both immediately after its execution (15.64 vs 17.94; p<0.0001), and in the years following (15.64 vs 17.39; p<0.0001). The latest audit cycle revealed that surgeons who joined the trust after October 2021, scored lower on average than those present during the proforma's introduction (15.43 vs. 17.71; p < 0.0001). Conclusions The implementation of a new electronic operation note proforma, designed in accordance with RCSEng guidelines, resulted in a sustained improvement in documentation over a significant time period. The slight discrepancy in scores between old and new members of the team could emphasise the importance of effective communication in ensuring the continuity of quality improvement projects.