Standardising Post-Operative Discharge Instructions in OMFS: A Two-Cycle Audit

Introduction
Discharge summaries provide an essential overview of admission and post-operative care. Clear discharge instructions are critical for patient safety, recovery, and overall healthcare experience, while also reducing administrative burden on clinical teams.

Aims
1. To evaluate whether discharge instructions for patients undergoing orthognathic surgery and mandibular open reduction and internal fixation (ORIF) at a single centre met consultant consensus guidelines.
2. To implement a discharge summary proforma with targeted education.
3. To re-audit performance following intervention.

Methods
Twenty consecutive cases of orthognathic surgery (bilateral sagittal split osteotomy, bimaxillary osteotomy, Le Fort I osteotomy) and mandibular ORIF between July–October 2024 at the John Radcliffe Hospital were retrospectively reviewed. Consultant consensus defined optimal discharge instructions for each group. Proforma-based discharge summary templates were developed and disseminated to resident doctors and dental core trainees alongside in-person teaching. A further twenty cases between April–June 2025 were re-audited. Completeness of discharge instructions was compared using the Mann-Whitney U test.

Results
In the second cycle, templates were used in 70% of orthognathic cases and 60% of mandibular fracture cases. There was a significant improvement in the total number of relevant discharge instructions included for both orthognathic surgery (p = 0.0000006) and mandibular fractures (p = 0.0001).

Discussion
The introduction of discharge summary templates and in-person education for resident doctors and dental core trainees significantly improved the quality of written discharge instructions. Although patient safety outcomes and patient satisfaction were not directly assessed, it is likely that clearer, standardised advice contributes to improved recovery and continuity of care. This approach could be readily adapted for other OMFS procedures and surgical specialties to standardise practice.

Conclusion
Standardised discharge templates combined with structured education improved post-operative documentation quality. Wider adoption of standardised proformas may enhance patient safety and clinical efficiency.