Background The European Association of Urology (EAU) recommends that the operative steps and documentation necessary for successful and appropriate management of bladder cancer include identifying factors necessary to assign disease risk stratification, clinical stage, adequacy of resection and the presence of complications and immediate intravesical chemotherapy administration. Aim To assess and improve the adequacy of current transurethral resection of bladder tumour (TURBT) documentation at a district general hospital in the UK against the EAU 2022 guidelines. Methods Operative notes over a one-year period were assessed for the inclusion of key steps to achieve a comprehensive TURBT as outlined by EAU guidelines. Outcomes included documentation on the details of the operative findings and intervention as well as the perioperative assessment. A standardised template for TURBT procedures was created and surgical staff received training on its usage. The audit was subsequently repeated after six months to assess for improvements. Results TURBT documentation of 78 cases in the first cycle was compared to 37 cases from the second cycle. Significant improvements in the documentation of tumour size (46% to 89%; p<0.05), tumour description (59% to 89%; p <0.05), depth of resection (36% to 89%; p<0.05), administration of chemotherapy (21% to 46%; p<0.05) and assessment for perforation (22% to 68%; p=0.001) were demonstrated. Improvements in pre-operative and post-operative examination rates under anaesthesia also achieved statistical significance (47% & 14% respectively to 89%; p<0.05). There was an increase in the documentation of completeness of resection but this did not achieve statistical significance (59% to 68%; p=0.42). Conclusion The operative note template led to the improvement in the documentation, improving the risk stratification of bladder cancer in patients undergoing TURBT. The use of procedure-specific operative note templates should be adopted for all commonly performed procedures to improve the completeness of documentation.
Keywords: clinical documentation improvement; guideline; non-muscle invasive bladder cancer; operation note; turbt.
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