Improving operative documentation in colorectal cancer surgery: synoptic notes pave the way forward.
BCCA
surgical audit
synoptic operative reports
Journal
ANZ journal of surgery
ISSN: 1445-2197
Titre abrégé: ANZ J Surg
Pays: Australia
ID NLM: 101086634
Informations de publication
Date de publication:
07 2022
07 2022
Historique:
revised:
14
02
2022
received:
18
12
2021
accepted:
04
03
2022
pubmed:
30
3
2022
medline:
13
8
2022
entrez:
29
3
2022
Statut:
ppublish
Résumé
Synoptic operative reports may improve reporting of key operative information. This study aimed to compare information included in synoptic reports with narrative notes following the introduction of a synoptic reporting system at a tertiary colorectal cancer referral centre. A standardized synoptic template incorporating the operative fields in the Australasian Bi-National Colorectal Cancer Audit (BCCA) was introduced for colorectal cancer surgery at the host institution in 2017. Colorectal cancer patients were identified from a prospectively collected database to collate samples of synoptic and narrative operative reports for comparison. The primary outcome was reporting of colon and rectal cancer-specific quality measures. Synoptic reporting of quality measures by clinician grade and uptake of synoptic reporting were also measured. Five hundred and ninety-five operative reports were reviewed; 84% of all quality measures were included in synoptic reports and 43% in narrative reports describing colon cancer surgery (P <0.001). Synoptic reports describing rectal cancer surgery included 84% of quality measures with 40% reported in narrative reports (P <0.001). Reporting for most individual quality measures did not change depending on clinician experience. Synoptic reporting methods were used to document 80% of all colon cancer surgery and 84% of rectal cancer surgery. Synoptic operative reports were superior to narrative reports in documenting quality measures. Synoptic reporting facilitates simultaneous data capture and bulk upload for audits including the BCCA. Development of synoptic operative reports standardized across Australasian colorectal cancer centres should be further investigated as a tool to facilitate collaborative audit and research.
Sections du résumé
BACKGROUND
Synoptic operative reports may improve reporting of key operative information. This study aimed to compare information included in synoptic reports with narrative notes following the introduction of a synoptic reporting system at a tertiary colorectal cancer referral centre.
METHODS
A standardized synoptic template incorporating the operative fields in the Australasian Bi-National Colorectal Cancer Audit (BCCA) was introduced for colorectal cancer surgery at the host institution in 2017. Colorectal cancer patients were identified from a prospectively collected database to collate samples of synoptic and narrative operative reports for comparison. The primary outcome was reporting of colon and rectal cancer-specific quality measures. Synoptic reporting of quality measures by clinician grade and uptake of synoptic reporting were also measured.
RESULTS
Five hundred and ninety-five operative reports were reviewed; 84% of all quality measures were included in synoptic reports and 43% in narrative reports describing colon cancer surgery (P <0.001). Synoptic reports describing rectal cancer surgery included 84% of quality measures with 40% reported in narrative reports (P <0.001). Reporting for most individual quality measures did not change depending on clinician experience. Synoptic reporting methods were used to document 80% of all colon cancer surgery and 84% of rectal cancer surgery.
CONCLUSION
Synoptic operative reports were superior to narrative reports in documenting quality measures. Synoptic reporting facilitates simultaneous data capture and bulk upload for audits including the BCCA. Development of synoptic operative reports standardized across Australasian colorectal cancer centres should be further investigated as a tool to facilitate collaborative audit and research.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1754-1759Informations de copyright
© 2022 Royal Australasian College of Surgeons.
Références
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