Skip to main content
  1. Right Decisions
  2. Maternity & Gynaecology Guidelines
  3. Gynaecology
  4. Back
  5. Gynaecology guidelines
  6. Operation note documentation - guideline for completion (1079)
Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Operation note documentation - guideline for completion (1079)

Warning

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