MP65-16 CREATION OF A STANDARDIZED HYPOSPADIAS TEMPLATE IN THE ELECTRONIC MEDICAL RECORD

Abstract

You have accessJournal of UrologyPediatrics: Hypospadias and Penile Surgery (MP65)1 Apr 2020MP65-16 CREATION OF A STANDARDIZED HYPOSPADIAS TEMPLATE IN THE ELECTRONIC MEDICAL RECORD Christopher Long*, Luis Braga, John Wiener, Mark Zaontz, and Melise Keays Christopher Long*Christopher Long* More articles by this author , Luis BragaLuis Braga More articles by this author , John WienerJohn Wiener More articles by this author , Mark ZaontzMark Zaontz More articles by this author , and Melise KeaysMelise Keays More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000940.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The lack of standardized reporting in hypospadias limits quality improvement and comparative effectiveness research. Variability in surgical decision making and reported complication rates in hypospadias surgery warrants further study to improve care delivery outcomes. Barriers to collaboration include small patient number, single institution efforts, and variability in patient assessment and reporting. Our goal was to create a document that could be shared across institutions, standardizing the documentation process. METHODS: A review of currently existing hypospadias scoring systems, data collection forms from existing registries (INSPIRE, HOLD) and expert opinion identified various datapoints for documentation. Expert feedback was obtained to determine necessary elements for surgical billing, a complete operative note and data elements for hypospadias reporting. Collaboration with an electronic health record (EHR) vendor established reportable data elements. A standardized clinical documentation form was created for preoperative measurements, intra-operative details and post-operative follow-up was created. RESULTS: An EHR standardized document was created for both documentation and research purposes (Figure 1). The operative note includes the type of repair, the planned intervention, type of anesthesia. The initial operative assessment includes the location of the urethral meatus, associated scrotal anomalies, the presence and degree of penile curvature, and the quality of the urethral plate. Specifics for orthoplasty, glansplasty, and urethroplasty are captured. Further granular details such as suture utilization, use of barrier layers, and duration of stent placement amongst others are also included, if the user elects to utilize them. The follow up note includes both functional and cosmetic assessment, reporting complications in a standardized fashion. CONCLUSIONS: This template standardizes the documentation of both intraoperative and follow up patients with hypospadias; it serves the dual purpose of clinical documentation and quality reporting. Furthermore, this will facilitate collaboration across institutions to improve the quality of the urologic literature. We present this work to foster broad utilization across centers. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e979-e980 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Long* More articles by this author Luis Braga More articles by this author John Wiener More articles by this author Mark Zaontz More articles by this author Melise Keays More articles by this author Expand All Advertisement PDF downloadLoading ...