title: The impact of an operative note proforma at a paediatric surgical centre.
abstract: OBJECTIVE
  With expectations for standardization and evidence-based practice, the Royal College of Surgeons (RCS) published the 'Good Surgical Practice' in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico-legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma.
  
  
  METHODS
  All general surgery and urology admissions during July 2011 and August 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in February 2012. Results were compared and statistically analysed using two-tailed Fisher's exact test, with Bonferroni correction where appropriate (SPSS 20.0, IBM SPSS Statistics, Armonk, NY, USA).
  
  
  RESULTS
  There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistant's name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetist's name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% (P<0.05). Subgroup analysis in the latter cohort shows most of these effects to be related to the use of the proforma rather than education alone (P<0.05). Quality of documentation was better by consultants versus trainees in 2 of 23 criteria (P<0.05).
  
  
  CONCLUSIONS
  We have demonstrated a simple and cost-effective way of improving the quality of operative documentation, in line with guidelines set out by the RCS, in a climate of increasing economic austerity.
authors.affiliation: Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.
authors.forename: Benjamin K Y
authors.initials: BK
authors.lastname: Chan
authors.forename: Klaire
authors.initials: K
authors.lastname: Exarchou
authors.forename: Harriet J
authors.initials: HJ
authors.lastname: Corbett
authors.forename: Rick R
authors.initials: RR
authors.lastname: Turnock
mesh_terms: D000758:Anesthesia; D003362:Cost-Benefit Analysis; D004282:Documentation / Q000592:standards*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008485:Medical Audit; D061646:Operative Time; D062209:Patient Handoff; D010355:Patient Identification Systems; D061214:Patient Safety; D010372:Pediatrics; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000592:standards*
keywords: Royal College of Surgeons; clinical guidelines; operation note; paediatric surgery; proforma