Recording Clinical Data across a Surgical Patient’s Pathway

Aims – To audit recording of data in medical records, from medicine use & allergy status, to evidencing infection risk discussions & operation notes. Methods – Two retrospective audits, involving 26 and 30 patients who were admitted in 2008/09 and 2011 respectively, for procedures carried out by general surgeons. Parts of guidelines that compliance was measured against included NICE PSG1, medicines reconciliation, NICE CG74, prevention of surgical site infection, and SIGN CG77, post-operative management. A data collection sheet was devised and used for both audits. Results – Improvement in rate of medicines reconciliation, from 81% to 90%, and more doctors conducting them, from 15% to 87%. Deterioration of proof patients have been informed about infection risks of surgery, 85% for pre-2010 patients and 7% for post-2010 patients. Comparable rates of filing of operation notes, 85% and 77% respectively, were found. Conclusions – Implementation of Trust policies and standard operating procedures have improvement medicines reconciliation and allergy status recording. Similar changes need to be made to achieve improved patient education of infection prevention, plus general recording of events throughout a surgical patient’s pathway. Auditing a whole patient pathway can help to identify gaps in practice.