Quality of inguinal hernia operative reports: room for improvement

Abstract

Background: Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. Methods:A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. Results:We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repairspecific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). Conclusion:Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.Contexte : Les notes opératoires (NO) servent à documenter officiellement les interventions chirurgicales. Elles sont indispensables à des soins optimaux aux patients, à l'imputabilité des médecins, à la facturation de leurs actes, à l'orientation de la recherche clinique et aux vérifications. Les notes narratives non standardisées sont souvent de piètre qualité et incomplètes. Nous avons voulu vérifier l'exhaustivité des notes opératoires narratives concernant les réparations d'hernies inguinales (RHI).Méthodes : Une équipe de 4 chirurgiens a créé une liste de vérification standardisée consensuelle comprenant 33 variables applicables à la RHI. Cinq chirurgiens experts des RHI ont classé ces éléments selon qu'ils leurs semblaient essentiels, préférables ou non essentiels. Nous avons passé en revue les NO des RHI ouvertes effectuées dans 6 hôpitaux universitaires.Résultats : Nous avons passé en revue 213 NO et nous avons exclus les NO concernant 7 hernies fémorales. Les réparations sans tension se sont révélées les plus communes (82,5 %) et la technique plug-and-patch a été la plus fréquente (52,9 %). Les résidents ont dicté 59 % des NO. Sur les 33 variables, 15 étaient considérées essentielles et en moyenne, 10,8 ± 1,3 ont été incluses dans les NO. Parmi les éléments qui laissaient à désirer, mentionnons : première réparation c. réparation récurrente (8,3 %), viabilité du g...

An audit of the quality of surgical operation notes in a Nigerian teaching hospital

“…With the invention of the printing press by the Germans in 1450, documentation about patients gradually became more widespread. 2 The importance of operation notes cannot be over-emphasized for several reasons, viz, the matter written in the notes affect patient care, are important in record keeping, are valuable in research, innovative strategies and are imperative for legal matters [3][4][5] . It is thus important that operation notes are accurately filled and should adequately represent the patient's details so as to assist with the immediate and long-term care of patients.…”

Implementation of a synoptic operative note for abdominal wall hernia repair: a statewide pilot evaluating completeness and communication of intraoperative details

“…Up to two-thirds of hernia operative notes are missing a key clinical detail of the operation, and despite synoptic operative notes improving documentation in other domains, they have yet to be implemented among hernia surgeries [4,[6][7][8]. In our multi-institution implementation of a synoptic operative note for hernia repairs, a level of surgeon resistance to altering current practices was reported.…”

“…A major barrier to characterizing variation in intra-operative techniques which directly affects outcomes, is the lack of standardized reporting on hernia-specific elements. Operative notes are inconsistent with regard to key details such as hernia size, location, use of mesh, and mesh placement that must be understood to develop best practices and ensure appropriate care for persons with recurrent disease [2][3][4]. Current evidence suggests up to 67% of hernia operative notes are missing at least one of these important operative characteristics [3,4].…”

“…Operative notes are inconsistent with regard to key details such as hernia size, location, use of mesh, and mesh placement that must be understood to develop best practices and ensure appropriate care for persons with recurrent disease [2][3][4]. Current evidence suggests up to 67% of hernia operative notes are missing at least one of these important operative characteristics [3,4]. Consistent operative documentation would aid in the collection of patient outcomes and long-term data, and allow for an understanding of how to best-serve patients [5].…”

Vollständigkeit und Plausibilität von Operationsberichten: Eine retrospektive Analyse der Dokumentationsqualität am Beispiel des Morbus Dupuytren

“…Bisher beschäftigten sich nur wenige Autoren mit der Analyse der Qualität von Operationsberichten. Die meisten Studien zu diesem Thema wurden in Kanada durchgeführt und evaluierten die Dokumentationsqualität onkologischer Operationen [2][3][4][5][6][7][8][9][10][11]. Ziel unserer retrospektiven Studie war es, zum einen die Vollständigkeit von Operationsberichten anhand des Beispiels des Morbus Dupuytren zu untersuchen und in einem weiteren Schritt die Exaktheit der Angaben zu prüfen.…”