Abstract
BackgroundProper documentation is an essential part of patient safety and quality of care in the surgical field. Surgical procedures are traditionally documented in narrative operative reports which are subjective by nature and often lack essential information. This systematic review will analyze the added value of the newly emerged synoptic reporting technique in the surgical setting.MethodsA systematic review was conducted to compare the completeness and the user-friendliness of the synoptic operative report to the narrative operative report. A literature search was performed in EMBASE, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, and Google Scholar for studies published up to April 6, 2018. The Newcastle–Ottawa Scale was utilized for the risk of bias assessment of the included articles. PROSPERO registration number was: CRD42018093770.ResultsOverall and subsection completion of the operative report was higher in the synoptic operative report. The time until completion of the operative report and the data extraction time were shorter in the synoptic report. One exception was the specific details section concerning the operative procedure, as this was generally reported more frequently in the narrative report. The use of mandatory fields in the synoptic report resulted in more completely reported operative outcomes with completion percentages close to 100%.ConclusionsThe synoptic operative report generally demonstrated a higher completion rate and a much lower time until completion compared to the traditional narrative operative report. A hybrid approach to the synoptic operative report will potentially yield better completion rates and higher physician satisfaction.
Highlights
In the current medicine, all healthcare providers are obliged to properly document the care services provided
2101 studies were screened based on title and abstract
The Newcastle–Ottawa Scale (NOS) demonstrated that 93.8% of the studies earned above two stars for the Selection item, 18.8% of the studies earned above one star for the Comparability item, and 37.5% of the studies earned above two stars for the Outcome item (Table 3). These results suggest that nine studies [16, 17, 19,20,21,22,23,24, 28] could be considered of good quality and seven studies [13,14,15, 18, 25,26,27] of moderate quality
Summary
All healthcare providers are obliged to properly document the care services provided. Within this requirement lays the composition of the operative note, comprising the essence of a surgical intervention and an imperative part in the continuity of care [1]. Surgical procedures are traditionally documented in narrative operative reports which are subjective by nature and often lack essential information. Methods A systematic review was conducted to compare the completeness and the user-friendliness of the synoptic operative report to the narrative operative report. Conclusions The synoptic operative report generally demonstrated a higher completion rate and a much lower time until completion compared to the traditional narrative operative report. A hybrid approach to the synoptic operative report will potentially yield better completion rates and higher physician satisfaction
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