Surgeons' perspectives on operation report documentation.
cleft lip and palate
clinical documentation
narrative report
operation report
plastic and reconstructive surgery
surgical education
synoptic report
Journal
ANZ journal of surgery
ISSN: 1445-2197
Titre abrégé: ANZ J Surg
Pays: Australia
ID NLM: 101086634
Informations de publication
Date de publication:
11 2023
11 2023
Historique:
revised:
24
06
2023
received:
11
04
2023
accepted:
09
07
2023
medline:
29
11
2023
pubmed:
27
7
2023
entrez:
27
7
2023
Statut:
ppublish
Résumé
Operation report documentation is essential for safe patient care and team communication, yet it is often imperfect. This qualitative study aims to understand surgeons' perspectives on operation report documentation, with surgeons reviewing cleft palate repair operation reports. It aims to determine how surgeons write an operation report (in narrative and synoptic report formats) and explore the consequences of incomplete documentation on patient care. A qualitative semi-structured interview was conducted with cleft surgeons who were asked to consider operation reports and hypothetical clinical cases. Eight operation reports performed at one centre for cleft palate repair were randomly selected for review. An operation report's purpose-patient care, complication documentation, future surgery, and research-will influence the detail documented. All cleft palate repair operation reports had important information missing. Synoptic report writing provides clearer documentation; however, narrative report writing may be a more robust communication and education tool. Surgeons described a bell-curve response in the level of training required to document an operation report-residents knew too little, fellows documented clearly, and Consultants documented briefer reports to highlight salient points. An understanding of surgeons' perspectives on operation report documentation is richer after this study. Surgeons know that clear documentation is essential for patient care and a skill that must be taught to trainees; barriers may be the documentation method. The flexibility of a hybrid operation report format is necessary for surgical care.
Sections du résumé
BACKGROUND
Operation report documentation is essential for safe patient care and team communication, yet it is often imperfect. This qualitative study aims to understand surgeons' perspectives on operation report documentation, with surgeons reviewing cleft palate repair operation reports. It aims to determine how surgeons write an operation report (in narrative and synoptic report formats) and explore the consequences of incomplete documentation on patient care.
METHODS
A qualitative semi-structured interview was conducted with cleft surgeons who were asked to consider operation reports and hypothetical clinical cases. Eight operation reports performed at one centre for cleft palate repair were randomly selected for review.
RESULTS
An operation report's purpose-patient care, complication documentation, future surgery, and research-will influence the detail documented. All cleft palate repair operation reports had important information missing. Synoptic report writing provides clearer documentation; however, narrative report writing may be a more robust communication and education tool. Surgeons described a bell-curve response in the level of training required to document an operation report-residents knew too little, fellows documented clearly, and Consultants documented briefer reports to highlight salient points.
CONCLUSIONS
An understanding of surgeons' perspectives on operation report documentation is richer after this study. Surgeons know that clear documentation is essential for patient care and a skill that must be taught to trainees; barriers may be the documentation method. The flexibility of a hybrid operation report format is necessary for surgical care.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
2626-2630Informations de copyright
© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.
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