An Opportunity in Op-Notes

Rudra, Shalini; Kieffer, W K M; Briffa, Norman; Kantak, Avadhoot

doi:10.1177/175045891502501004

Cited by 3 publications

(9 citation statements)

References 4 publications

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“…The NOS demonstrated that 93.8% of the studies earned above two stars for the Selection item, 18.8% of the studies earned above one star for the Comparability item, and 37.5% of the studies earned above two stars for the Outcome item (Table 3). These results suggest that nine studies [16, 17, 19–24, 28] could be considered of good quality and seven studies [13–15, 18, 25–27] of moderate quality.…”

Section: Resultsmentioning

confidence: 92%

“…Overall NRs in oncological thyroidectomies documented the presence/absence of tumor invasion in 27% of the cases, completeness of resection in 3%, and tumor size in 29%, whereas these were recorded in 100% of the cases in SRs ( p < .001) [15]. Other studies consistently showed higher overall completion rates in SRs [21, 25, 26, 28].…”

Section: Resultsmentioning

confidence: 99%

“…A total of 2059 articles were not relevant for the reviewed question. The eligibility of the remaining 42 articles was assessed based on full-text review, of which 16 met the inclusion criteria [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. The study selection process is depicted in Fig.…”

Section: Literature Searchmentioning

confidence: 99%

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A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery

2019

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Background Proper documentation is an essential part of patient safety and quality of care in the surgical field. Surgical procedures are traditionally documented in narrative operative reports which are subjective by nature and often lack essential information. This systematic review will analyze the added value of the newly emerged synoptic reporting technique in the surgical setting. Methods A systematic review was conducted to compare the completeness and the user-friendliness of the synoptic operative report to the narrative operative report. A literature search was performed in EMBASE, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, and Google Scholar for studies published up to April 6, 2018. The Newcastle-Ottawa Scale was utilized for the risk of bias assessment of the included articles. PROSPERO registration number was: CRD42018093770. Results Overall and subsection completion of the operative report was higher in the synoptic operative report. The time until completion of the operative report and the data extraction time were shorter in the synoptic report. One exception was the specific details section concerning the operative procedure, as this was generally reported more frequently in the narrative report. The use of mandatory fields in the synoptic report resulted in more completely reported operative outcomes with completion percentages close to 100%. Conclusions The synoptic operative report generally demonstrated a higher completion rate and a much lower time until completion compared to the traditional narrative operative report. A hybrid approach to the synoptic operative report will potentially yield better completion rates and higher physician satisfaction.

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Section: Resultsmentioning

confidence: 92%

Section: Resultsmentioning

confidence: 99%

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A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery

2019

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“…Operative notes are an essential document for the post-operative management of patients [ 7 ]. The RCS guideline is instructive about the prescription for legibility, details of information and timing of completion of op notes [ 3 , 8 ]. As evident from our result, 78% of the op notes were written by the registrar and junior trainees (Figure 1 ) who may not have received any formal training [ 7 , 9 ].…”

Section: Discussionmentioning

confidence: 99%

Improving Compliance With Operative Note Guidelines Through the Implementation of an Electronic Proforma

Oladeji¹,

Singh²,

Kastos³

2022

Cureus

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Background An operative note (op note) is a vital medical record of remarkable clinical, medico-legal and academic relevance. The Royal College of Surgeons (RCS) has set out a guideline to standardise op notes. This closed-loop audit assessed the compliance of op notes completed in our local hospital against the guidance set by RCS with the view to identify deficiencies and improve practice. Methods A retrospective review of general surgery operative notes was carried out to access their various characteristics against RCS guidance. Two additional parameters were assessed, namely, ‘cadre of the surgeon that completed the op note’ and ‘use of abbreviations’. To improve compliance with RCS guidelines, an electronic proforma (EP) that included all the 18 characteristics listed in good surgical practice was implemented and a re-audit was undertaken six months afterwards. Results A total of 200 op notes were reviewed, 98 during the initial audit cycle and 102 at the re-audit. Seventy-eight per cent (78%) of the op notes were written by trainees. At the initial audit, seven parameters performed poorly, with compliance ranging between 5.1% and 76.5%. The re-audit demonstrated improved adherence to guidelines following the implementation of the EP, as well as a reduction in the use of abbreviations. The overall compliance improved from roughly 80% to >95%. Conclusion A sustainable change was achieved through the implementation of EP with improvement demonstrated in content and structure. The need to provide teaching to trainees who are responsible for writing a vast majority of op notes was identified.

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“…[ 3 , 4 ] By now, most surgeons make use of templates for documentation as this can verifiably improve quality. [ 5 ] In addition, structured operative notes with a predefined wording empower automated information extraction (IE) for economic and scientific applications apart from a bare medical significance. [ 6 ] An obvious approach to foster a reliable yet applicatory surgical reporting is the use of computer science.…”

Section: Introductionmentioning

confidence: 99%

Surgical reporting for laparoscopic cholecystectomy based on phase annotation by a convolutional neural network (CNN) and the phenomenon of phase flickering: a proof of concept

et al. 2022

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Purpose Surgical documentation is an important yet time-consuming necessity in clinical routine. Beside its core function to transmit information about a surgery to other medical professionals, the surgical report has gained even more significance in terms of information extraction for scientific, administrative and judicial application. A possible basis for computer aided reporting is phase detection by convolutional neural networks (CNN). In this article we propose a workflow to generate operative notes based on the output of the TeCNO CNN. Methods Video recordings of 15 cholecystectomies were used for inference. The annotation of TeCNO was compared to that of an expert surgeon (HE) and the algorithm based annotation of a scientist (HA). The CNN output then was used to identify aberrance from standard course as basis for the final report. Moreover, we assessed the phenomenon of ‘phase flickering’ as clusters of incorrectly labeled frames and evaluated its usability. Results The accordance of the HE and CNN was 79.7% and that of HA and CNN 87.0%. ‘Phase flickering’ indicated an aberrant course with AUCs of 0.91 and 0.89 in ROC analysis regarding number and extend of concerned frames. Finally, we created operative notes based on a standard text, deviation alerts, and manual completion by the surgeon. Conclusion Computer-aided documentation is a noteworthy use case for phase recognition in standardized surgery. The analysis of phase flickering in a CNN’s annotation has the potential of retrieving more information about the course of a particular procedure to complement an automated report.

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An Opportunity in Op-Notes

Cited by 3 publications

References 4 publications

A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery

A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery

Improving Compliance With Operative Note Guidelines Through the Implementation of an Electronic Proforma

Surgical reporting for laparoscopic cholecystectomy based on phase annotation by a convolutional neural network (CNN) and the phenomenon of phase flickering: a proof of concept

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