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Operation note documentation - guideline for completion (1079)

Objectives

To provide a standardised method for documentation of operative procedures in Gynaecology

Audience

All Healthcare professionals undertaking and documenting operative procedures in Gynaecology

Please report any inaccuracies or issues with this guideline using our online form

It is recognised that good communication is essential to the provision of effective and safe healthcare provision.  Communication errors between doctors and patients, and between healthcare professionals, can results in patients being harmed or receiving substandard care.

The Royal College of Surgeons of England provide advice, particularly relating to the documentation of operative procedures.  This includes ensuring that operation notes are clear and preferably typed, and available for every procedure.  The operation note should accompany the patient into recovery and when transferred to the ward.  Each operation note should provide sufficient information to enable continuity of care with different healthcare teams.

Additionally, documentation of the extent of specimen removed at time of operation is essential, particularly documentation of removal of cervix at time of hysterectomy.

The standard of documentation within Gynaecology in GGC is outlined in Appendix I.

APPENDIX I: OPERATION NOTE DOCUMENTATION – SURGICAL CHECKLIST

Date

Members of staff in theatre

  • Surgical team – names and designations
  • Anaesthetic team - names and designations
  • Scrub team – names and designations
  • Additional specialities – names and designations

Surgical procedure including

  • Additional procedures undertaken
  • Urgency of procedure - Emergency or elective

Procedure indication

Procedure Findings

Blood loss – Estimated / Measured Blood Loss (EBL or MBL)

Procedure details including:

  • Antibiotic prophylaxis
  • Energy modality utilised where appropriate
  • Complications
  • Wound closure technique
  • Packs or drains used
  • Swab, needle and instrument count

Post-operative instructions including:

  • Specimens removed (if hysterectomy specimen document if cervix removed)
  • Urgent or routine pathology analysis of specimen requested
  • DVT prophylaxis
  • ERAS (enhanced recovery after surgery) care
  • Timing for pack/drain/catheter removal
  • Analgesia
  • antibiotics

Estimated date of discharge

Follow up plan

Editorial Information

Last reviewed: 23/09/2024

Next review date: 31/03/2028

Author(s): Dr Aradhana Khaund, Consultant O&G.

Version: 2

Approved By: Gynaecology Clinical Governance Group

Reviewer name(s): Dr Claire Higgins.

Document Id: 1079

References

A scoping review of evidence relating to communication failures that lead to patient harm. Campbell P, Torrens C, Pollock A, Maxwell M. September 2018 commissioned by the Chief Nursing Officer for Scotland and the General Medical Council.

1.3 Record your work clearly, accurately and legibly — Royal College of Surgeons