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

Abstract

A surgical report is the surgeon's postoperative documentation of the procedure undertaken. The purpose of this study was to evaluate the completeness and accuracy of data extracted from surgical reports, using the example of Dupuytren's disease. Between 1999 and 2007, surgical data were retrospectively collected from all primary Dupuytren's disease procedures performed at an academic department for plastic and reconstructive surgery and analysed for completeness. A surgical report was assessed as complete if data on indication, affected side and finger(s), tourniquet, type of incision and surgical procedure were stated. Surgical reports of residents and consultants were compared with respect to completeness. For the assessment of accuracy, total fasciectomy procedure reports were compared with intra- and postoperative photo-documentation. 424 surgical reports of 366 patients were analysed, 275 created by consultants, 149 by residents. Although 49.5 % of all surgical reports were complete, the indication for surgery was omitted in 53 cases. Information on the affected side and finger(s) was missing in 13 and 6 cases, respectively. In 29 reports, no documentation on tourniquet was found, in 5 the surgical method and in 82 reports the type of incision was lacking. A significant difference between surgical reports of residents and consultants was found for documentation of indication and severity of the Dupuytren's disease, as well as the tourniquet, in favour of residents (p < 0.0001). In 37 surgical reports, total fasciectomy was performed, 26 with intra- or postoperative photodocumentation. By comparison, in 11 of 26 cases (42 %), total fasciectomy could not have been performed. Surgical reports are sometimes incomplete and imprecise, independently of whether they were created by residents or consultants. Although they are intended as documentation for doctors and not for forensic reasons, it should be in the surgeon's interest to create complete and exact reports. As surgical reports are part of the patient's chart, surgical associations should develop guidlines with information that should manditorily included in surgical reports.