New guidance for best practice in surgical documentation

Best practice guidance for the effective documentation of five common surgical procedures is now available, to help improve the investigation of episodes of care if they lead to patient safety incidents or NHS litigation claims.

Getting It Right First Time (GIRFT) has worked with NHS Resolution, the Royal College of Surgeons of England (RCS England), the Association of Surgeons of Great Britain (ASGBI), and the British Association of Endocrine & Thyroid Surgeons (BAETS) to create the guides, outlining how clear documentation of procedures can support the resolution process and provide the best care and satisfactory outcomes for patients.

The guides cover laparoscopic appendicectomy, laparoscopic cholecystectomy, open and laparoscopic inguinal hernia, laparotomy and laparoscopic bowel resection surgery and thyroidectomy, and include case studies to illustrate the importance and impact of improving documentation. They can be found in GIRFT’s FutureNHS workspace (log in required) and Best Practice Library.

The current cost of litigation against the NHS in England is £128.6bn and activity is increasing. The new guidance has arisen from a review of claims data with NHS Resolution, plus feedback from NHS panel firm lawyers and expert witnesses, showing that poor documentation often makes the investigation of episodes of care leading to incidents and claims difficult and can prevent the defence of potentially good clinical practice.