Quality of narrative operative reports in pancreatic surgery

Abstract

Background: Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy. Methods:We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness. Results:We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration. Conclusion:The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care. Conclusion :Les NO sont souvent incomplètes et leur qualité laisse à désirer. Des éléments importants, dont le protocole opératoire et les données oncologiques, étaient souvent manquants. Ainsi, les NO constituent une source inadéquate de données en ce qui concerne les IQ. Il faudra encourager la mise au point et l'utilisation d'autres types de rapports, dont des synopsis opératoires standardisés, pour mieux documenter les soins chirurgicaux prodigués et pour en évaluer la qualité. Q uality improvement is an important component of health care systems. Quality in health care can be evaluated in terms of the structures, processes and outcomes of care.

Imaging for Quality Control: Comparison of Systematic Video Recording to the Operative Note in Colorectal Cancer Surgery. A Pilot Study

“…About half of the steps in the operative note were described in an adequate manner, which is in accordance with similar published findings in different fields of surgery 18–21. According to our results, adding systematic video recording to the traditional operative note would increase the total amount of available adequate information by almost 50 %.…”

Evaluating narrative operative reports for endoscopic sinus surgery in a residency training program

“…Their quality audit reinforced these perceptions, as the 40 Roux‐en‐Y gastric bypass NRs they analyzed contained only 62% ± 6.6% of the variables deemed necessary for inclusion. This lack of completeness within NRs was also found in NRs for pancreatic surgery (72.5% completeness for pancreaticoduodenectomy), breast surgery (66% completeness), and upper limb surgery (71.1% completeness) . That fact that our study found a higher average QI inclusion rate (85%) compared to these other studies may reflect the greater emphasis placed on documentation at our institution.…”

“…This lack of completeness within NRs was also found in NRs for pancreatic surgery (72.5% completeness for pancreaticoduodenectomy), breast surgery (66% completeness), and upper limb surgery (71.1% completeness). [13][14][15] That fact that our study found a higher average QI inclusion rate (85%) compared to these other studies may reflect the greater emphasis placed on documentation at our institution. Furthermore, junior residents have an informal template that they follow when learning how to dictate reports which could partially account for the fact that junior residents had a higher QI inclusion percentage than senior residents (87% vs 80%) (P .0169).…”

Synoptic operative reports enhance documentation of best practices for rectal cancer

“…Operative reports present a medium to record and potentially measure performance of important quality indicators that affect patients undergoing surgical procedures for cancer [5,6]. However, multiple studies have demonstrated that traditional narrative operative reports (NR) often lack important operative details, which make them inadequate for quality assurance purposes [6][7][8][9][10][11][12][13][14]. More recently, synoptic operative reports (SR), which use pre-defined procedure specific templates, have been developed to standardize operative reporting.…”