Usefulness of Royal College of Surgeons of England operation note guidelines to neurosurgical practice: a closed loop audit

Abstract

In the UK, doctors are instructed to keep accurate and clear medical records. This helps to ensure patient safety and is a professional expectation from the General Medical Council (GMC). However, operation note documentation is often reported to be sub-optimal despite general guidelines from the Royal College of Surgeons of England (RCSeng) existing. These guidelines have sub-domains, e.g. estimated blood loss, which can inform the understanding of an intra-operative complication to help guide post-operative management. We conducted a closed loop audit of operative notes against these guidelines to ascertain if neurosurgeons in our department thought them applicable to neurosurgical practice. The first cycle was conducted retrospectively and the second cycle prospectively each conducted over a four-week period. In between each cycle the results were presented to the department: firstly, as an oral presentation and secondly as posters displayed in relevant clinical areas. Furthermore, the knowledge of operative note guidelines and their perceived importance by registrars were ascertained through a questionnaire. This highlighted that RCSeng sub-domains missing from operation notes scored lowest in terms of importance, and one sub-domain that remained recorded less frequently in both cycles was estimated blood loss. This reflects closed loop audits in general, plastic and orthopaedic surgery. Clearly, a generic guideline cannot be completely applicable to neurosurgical practice. This then begs the question if such a guideline is useful at all. Or should guidelines be specialty specific, as is the case in orthopaedic surgery, to improve compliance to a guideline more reflective of neurosurgical practice.

Keywords:

• Neurosurgery
• clinical governance
• audit
• guidelines

Acknowledgements

The authors thank Mr. St. George, Consultant Neurosurgeon, and NHS Greater Glasgow & Clyde and the Department of Neurosurgery at the Institute of Neurological Sciences.

Disclosure statement

No potential conflict of interest was reported by the author(s).