Descriptive Operative Reports: Teaching, Learning, and Milestones to Safe Surgery

Porterfield, John R.; Altom, Laura K.; Graham, Laura A.; Gray, Stephen H.; Urist, Marshall M.; Hawn, Mary T.

doi:10.1016/j.jsurg.2011.06.015

Cited by 15 publications

(22 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The limitations of the study include its retrospective study design and lack of data on the level of training of and specialty of the person dictating the operation report. Studies have consistently demonstrated poorer quality of narrative operation reports dictated by residents versus surgical faculty [22][23][24][25]. In addition, although the surgeons involved in choosing important surgical variables are all experienced in CD surgery, they were not agreed upon using a standard Delphi survey [26].…”

Section: Discussionmentioning

confidence: 99%

Is synoptic operative reporting necessary for Crohn's disease surgery? Variability in surgical reports across inflammatory bowel disease referral centres

et al. 2021

View full text Add to dashboard Cite

Around 80% of Crohn's disease (CD) patients require an ileocolic resection (ICR) within 10 years of initial diagnosis, with about 50% of the patients developing a postoperative surgical recurrence [1][2][3]. ICR is the most common operation required for medically refractory disease. A number of surgical findings, including length of resected bowel, anastomotic technique/configuration and operative approach, may be associated with long-term outcomes after ICR [4][5][6][7]. Accordingly, the surgical report is a vital tool for accessing

show abstract

Section: Discussionmentioning

confidence: 99%

Is synoptic operative reporting necessary for Crohn's disease surgery? Variability in surgical reports across inflammatory bowel disease referral centres

et al. 2021

View full text Add to dashboard Cite

show abstract

“…Operative notes with accurate descriptions of procedural steps and findings can serve as learning tools for trainees and experienced practitioners alike, allowing for opportunities to analyze specific interventions and outcomes 11 . Deficiencies in documentation are pervasive and can have implications for physician reimbursement in addition to patient care, in a reduction of up to 9.7% 2,12,13 . Mentorship and training initiatives could help residents generate comprehensive operative notes.…”

Section: Discussionmentioning

confidence: 99%

Documentation in Pediatric Microlaryngoscopy/Bronchoscopy: International Modified Delphi Consensus

et al. 2022

View full text Add to dashboard Cite

Background: Complete and accurate documentation of surgical procedures is essential for optimizing patient care, yet significant variation in operative notes persists within and across institutions. We sought to reach consensus on the most important components of an operative note for pediatric microlaryngoscopy and bronchoscopy.Methods: A modified Delphi consensus process was used. A checklist for operative documentation, created by fellowshiptrained pediatric otolaryngologists-head and neck surgeons, was sent to surgeons identified as experts in pediatric laryngoscopy and bronchoscopy. In the first round, items were rated as "keep" or "remove". In the second round, each item was rated on a 7-point Likert scale for importance. The mean score of each item was calculated to determine if consensus was reached.Results: Overall, 43/74 (58.1%) surgeons responded to our survey. After two rounds of editing, 28 components reached consensus, 24 were near consensus, and 26 did not reach consensus. Items that reached final consensus had mean (SD) ratings of 6.12 (0.94) (range, 5.31-6.72).Conclusion: Pediatric otolaryngologists identified as bronchoscopy experts were able to create a checklist of essential components of an operative note for pediatric laryngoscopy and bronchoscopy using a Delphi method. Items reaching consensus included procedure name, description of breathing, grade of airway view, description of normal anatomic structures, grade of subglottic stenosis if present, presence and description of tracheobronchomalacia, presence of fistulae, cleft and rings, and several special cases including foreign body and tracheostomy management, as well as end of procedure disposition and complications.

show abstract

“…If such systems are in place, residents can be taught these methods for reporting during their training [3, 4]. As the era of digital photography and electronic medical records evolves, this is a very appropriate time to innovate with respect to the methods by which we document our surgical findings.…”

Section: Discussionmentioning

confidence: 99%

Standardization of Laparoscopic Pelvic Examination: A Proposal of a Novel System

Pope

Henry

Zanotti

et al. 2013

Minimally Invasive Surgery

View full text Add to dashboard Cite

Objective. Laparoscopic pelvic assessment is often performed in a nonstandardized fashion depending on the surgeon's discretion. Reporting anatomic findings is inconsistent and lesions in atypical locations may be missed. We propose a method for systematic pelvic assessment based on anatomical landmarks. Design. Retrospective analysis. Setting. Tertiary care academic medical center. Intervention. We applied this system to operative reports of 540 patients who underwent diagnostic or operative laparoscopy for unexplained infertility between 2006 and 2012. The pelvis was divided into 2 midline zones (zone I and II) and right and left lateral zones (zone III and IV). All reports were evaluated for the comprehensiveness of description with respect to normal findings or pathology for each zone. Results. Of 540 surgeries, all reports commented on the uterus, tubes, and ovaries (100%), but only 17% (n = 93, 95% CI: 13.8–20.2) commented on the dome of the bladder and the anterior cul-de-sac. 24% (n = 130, 95% CI: 20.4–27.6) commented on the posterior cul-de-sac, and 5% (n = 29, 95% CI: 3.2–6.8) commented on the pelvic sidewall. Overall, 6% (n = 34, 95% CI: 4–8) reported near complete documentation of the pelvic zones. Conclusion. Implementation of a systematic approach for laparoscopic pelvic examination will enhance the diagnostic accuracy and provide better communication between care providers. In the absence of pelvic pathology, we recommend a minimum of 6 photographs of the 6 pelvic zones.

show abstract

Descriptive Operative Reports: Teaching, Learning, and Milestones to Safe Surgery

Cited by 15 publications

References 16 publications

Is synoptic operative reporting necessary for Crohn's disease surgery? Variability in surgical reports across inflammatory bowel disease referral centres

Is synoptic operative reporting necessary for Crohn's disease surgery? Variability in surgical reports across inflammatory bowel disease referral centres

Documentation in Pediatric Microlaryngoscopy/Bronchoscopy: International Modified Delphi Consensus

Standardization of Laparoscopic Pelvic Examination: A Proposal of a Novel System

Contact Info

Product

Resources

About