Narrative Operative Reports Research Articles

Large language models can accurately populate Vascular Quality Initiative procedural databases using narrative operative reports.

Participation in the Vascular Quality Initiative (VQI) provides important resources to surgeons, but the ability to do so is often limited by time and data entry personnel. Large language models (LLMs) such as ChatGPT (OpenAI) are examples of generative artificial intelligence (AI) products that may help bridge this gap. Trained on large volumes of data, the models are used for natural language processing (NLP) and text generation. We evaluated the ability of LLMs to accurately populate VQI procedural databases using operative reports. A single-center retrospective study was performed using institutional VQI data from 2021-2023. The most recent procedures for carotid endarterectomy (CEA), endovascular aneurysm repair (EVAR) and infrainguinal lower extremity bypass (LEB) were analyzed using Versa, a HIPAA-compliant institutional version of ChatGPT. We created an automated function to analyze operative reports and generate a shareable VQI file using two models: gpt-35-turbo and gpt-4. Application of the LLMs was accomplished with a cloud-based programming interface. The outputs of this model were compared to VQI data for accuracy. We defined a metric as "unavailable" to the LLM if it was discussed by surgeons in <20% of operative reports. unavailable. 150 operative notes were analyzed, including 50 CEA, 50 EVAR, and 50 LEB. These procedural VQI databases included 25, 179, and 51 metrics, respectively. For all fields, gpt-35-turbo had a median accuracy of 84.0% for CEA (IQR 80.0-88.0%), 92.2% for EVAR (IQR 87.2-94.0%), and 84.3% for LEB (IQR 80.2-88.1%). There were 3 of 25, 6 of 179, and 7 of 51 VQI variables were unavailable in the operative reports, respectively. Excluding metric information routinely unavailable in operative reports, the median accuracy rate was 95.5% for each CEA procedure (IQR 90.9-100.0%), 94.8% (IQR 92.2-98.5) for EVAR, and 93.2% for LEB (IQR 90.2-96.4%). Across procedures, gpt-4 did not meaningfully improve performance compared to gpt-35 (p=0.97, 0.85, 0.95 for CEA, EVAR, LEB overall performance). The cost for 150 operative reports analyzed with gpt-35-turbo and gpt-4 were $0.12 and $3.39, respectively. LLMs can accurately populate VQI procedural databases with both structured and unstructured data, while incurring only minor processing costs. Increased workflow efficiency may improve center ability to successfully participate in the VQI. Further work examining other VQI databases and methods to increase accuracy are needed.

Documentation of critical intraoperative oncologic findings: Synoptic versus narrative operative reports for childhood cancer surgery.

Documentation of intraoperative oncologic findings varies greatly across narrative operative reports (NRs). An international panel of childhood cancer experts recently developed a synoptic operative report (SR) for childhood cancer surgeries. The aim of this study was to compare the documentation of critical intraoperative findings in NRs versus SRs. A single-center retrospective review of all surgical resections of primary solid tumors at our pediatric oncology center was conducted from June 2023 to March 2024, after an institutional SR was piloted from October 2023 onwards. Data collected included the presence or absence of six components included in standard pediatric oncology NRs. Inclusion rates were calculated as percentages for each component. Due to the small sample, the Fisher's exact test was used for all hypothesis testing. Seventy primary tumor resections were performed during the study period, as documented by 38 NRs and 32 SRs. All operative reports after October 2023 were SRs. Completeness of tumor resection and specimen naming were consistently documented in NRs (86% and 100%, respectively) and SRs (100% and 100%, respectively). The presence/absence of three components-intraoperative tumor spillage (31%), vascular involvement (31%), and lymph node sampling (26%)-were documented in fewer than a third of the NRs. Documentation of the presence/absence of locoregional spread, intraoperative tumor spillage, vascular involvement, and lymph node sampling was significantly better in SRs than in NRs. Adoption of SRs significantly improved the documentation of critical intraoperative findings. Thus, we recommend using SRs in pediatric solid tumor surgery.

An assessment of narrative operative reports for Wilms tumor resection using consensus component criteria.

Precision in surgical documentation is essential to avoid miscommunication and errors in patient care. Synoptic operative reports are more precise than narrative operative reports, however they have not been widely implemented in pediatric surgical oncology. To assess the need for implementation of synoptic operative reports in pediatric surgical oncology, we examined the completeness of narrative operative reports in patients undergoing resection of Wilms tumor. We conducted a retrospective review of narrative operative reports for resection of Wilms tumor at a single pediatric oncology center from January 2022 through July 2023. Primary outcomes were the presence or absence of 11 key operative report components. Inclusion rates were calculated as simple percentages. Unilateral and bilateral operations were considered. Thirty-five narrative reports for Wilms tumor resection were included. The most consistently documented operative report components were estimated blood loss, indication for surgery, intraoperative complications, and specimen naming (100% documentation rates). Documentation of lymph node sampling was present in 94.3% of reports. The least consistently documented components were assessment of intraoperative tumor spillage, completeness of resection, metastatic disease, and assessment of vascular involvement (each ≤40% documentation rate). All 11 key components were documented in three reports. Even at a large tertiary pediatric oncology referral center, narrative operative reports for pediatric Wilms tumor resection were found to be frequently missing important components of surgical documentation. Often, these were omissions of negative findings. Utilization of synoptic operative reports may be able to reduce these gaps.

Development of a Consensus-Derived Synoptic Operative Report for Rectal Prolapse: A Report From the Pelvic Floor Disorders Consortium.

Narrative operative reports may omit or obscure data from an operation. To develop a synoptic operative report for rectal prolapse that includes core descriptors as developed by an international consensus of expert pelvic floor surgeons. Descriptors for patients undergoing rectal prolapse surgery were generated through review. Members of the Pelvic Floor Disorders Consortium were recruited to participate in a 3-round Delphi process using a 9-point Likert scale. Descriptors that achieved 70% agreement were kept from the first round, and descriptors scoring 40% to 70% agreement were recirculated in subsequent rounds. A final list of operative descriptors was determined at a consensus meeting, with a final consensus meeting more than 70% agreement. This survey was administered to members of the Pelvic Floor Disorders Consortium. No patient data are included in this study. Descriptors meeting greater than 70% agreement were selected. One hundred seventy-six surgeons representing colorectal surgeons, urogynecologists, and urologists distributed throughout North America (56%), Latin America (4%), Western Europe (29%), Asia (4%), and Africa (1%) participated in the first round of Delphi voting. After 2 additional rounds and a final consensus meeting, 16 of 30 descriptors met 70% consensus. Descriptors that met consensus were surgery type, posterior dissection, ventral dissection, mesh used, type of mesh used, mesh location, sutures used, suture type, pouch of Douglas and peritoneum reclosed, length of rectum imbricated, length of bowel resected, levatoroplasty, simultaneous vaginal procedure, simultaneous gynecologic procedure, simultaneous enterocele repair, and simultaneous urinary incontinence procedure. The survey represents the views of members of the Delphi panel and may not represent the viewpoints of all surgeons. This Delphi survey establishes international consensus descriptors for intraoperative variables that have been used to produce a synoptic operative report. This will help establish defined operative reporting to improve clinical communication, quality measures, and clinical research. See Video Abstract . ANTECEDENTES:Los protocolos operativos narrativos frecuentemente pueden omitir u oscurecer datos de un procedimiento.OBJETIVO:Nuestro objetivo es desarrollar un protocolo operatorio sinóptico para el prolapso rectal que incluya descriptores básicos desarrollados por un consenso internacional de cirujanos expertos en piso pélvico.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron mediante revisión. Se reclutó a miembros del Consorcio de Trastornos del Piso Pélvico para participar en un proceso Delphi de 3 rondas utilizando una escala Likert de 9 puntos. Los descriptores que lograron un 70% de acuerdo se mantuvieron en la primera ronda, los descriptores que obtuvieron un 40-70% de acuerdo se recircularon en rondas posteriores. Se determinó una lista final de descriptores operativos en una reunión de consenso, con una reunión de consenso final de más del 70% de acuerdo.ESCENARIO:Esta fue una encuesta administrada a miembros del Consorcio de Trastornos del Piso Pélvico.PRINCIPALES MEDIDAS DE RESULTADO:Se seleccionaron los descriptores que cumplieron más del 70% de acuerdo.RESULTADOS:Ciento setenta y seis cirujanos en representación de cirujanos colorrectales, uroginecólogos y urólogos distribuidos en América del Norte (56%), América Latina (4%), Europa Occidental (29%), Asia (4%) y África (1%) participaron en la primera ronda de votación Delphi. Después de dos rondas adicionales y una reunión de consenso final, 16 de 30 descriptores alcanzaron un 70% de consenso. Los descriptores que alcanzaron consenso fueron: tipo de cirugía, disección posterior, disección ventral, malla utilizada, tipo de malla utilizada, ubicación de la malla, suturas utilizadas, tipo de sutura, cierre del fondo de saco de Douglas y peritoneo, longitud del recto superpuesto, longitud del intestino resecado, plastía de los elevadores , procedimiento vaginal simultáneo, procedimiento ginecológico simultáneo, reparación simultánea de enterocele y procedimiento simultáneo de incontinencia urinaria.LIMITACIONES:La encuesta representa las opiniones de los miembros del panel Delphi y puede no representar los puntos de vista de todos los cirujanos.CONCLUSIONES/DISCUSIÓN:Esta encuesta Delphi establece descriptores de consenso internacional para las variables intraoperatorias que se han utilizado para producir un protocolo operatorio sinóptico. Esto ayudará a establecer protocolos operativos definidos para mejorar la comunicación clínica, las medidas de calidad y la investigación clínica. (Traducción-Dr. Felipe Bellolio ).

Generative AI Can Accurately Populate Vascular Quality Initiative Procedural Databases Using Narrative Operative Reports

Generative AI Can Accurately Populate Vascular Quality Initiative Procedural Databases Using Narrative Operative Reports

Narrative operative reports inconsistently record surgical information relating to resection of soft tissue sarcomas and mast cell tumors in dogs.

To report to what degree narrative operative reports for soft tissue sarcoma (STS) and mast cell tumor (MCT) resections met a predetermined template made up of essential elements. 197 consecutive client-owned animals between May 1, 2017, and August 1, 2022. A consensus list of 9 elements made up the final synoptic operative report (SR) template. Consecutive narrative surgery reports (NRs) of dogs that underwent MCT or STS resection were then reviewed to determine how many of the SR elements were present in each NR. A score was then determined for each NR out of a maximum total of 9. Overall, 197 reports (99 MCT and 98 STS) were included. The median score was 5 (56% of elements reported). No report had all 9 elements, and 1 report had none of the elements reported. When MCT and STS were analyzed independently, the median score was 6 (67% of elements reported) for MCT and 5 (56% of elements reported) for STS. There was a trend of more cases with MCT that had a preoperative diagnosis, intraoperative measurements of the tumor, and surgeon margins marked compared to dogs with STS. More dogs with STS had an estimated Enneking dose compared to dogs with MCT. Our data show that essential elements of STS and MCT resection in dogs were inconsistently recorded and no case had all elements present. This mirrors data in people and presses the need for more standardization in reporting of cancer operations in veterinary medicine.

Development of a template for operative reporting of pediatric cancer surgery in limited-resource settings by using a modified Delphi method.

A comprehensive operative report for cancer surgery is crucial for accurate disease staging, risk stratification, and therapy escalation/de-escalation, which affects the outcome. Narrative operative reports may fail to include some critical findings. Furthermore, standardized operative reports can form the basis of a local registry, which is often lacking in limited-resource settings (LRSs). In adult literature, synoptic operative reports (SOR) contain more key findings than narrative operative reports. In the LRSs, where the capacity of diagnostic pathology services is typically suboptimal, the value of a thorough operative report is even greater. The aim of this study was to develop a SOR template to help standardize childhood cancer surgery reporting in LRSs. Twenty-three experts in pediatric cancer with extensive experience practicing in LRSs were invited to participate in a modified Delphi procedure. SOR domains for pediatric oncology surgery were drafted based on a literature search and then modified based on experts' opinions. The experts anonymously answered multiple rounds of online questionnaires until all domains and subdomains reached a consensus, which was predefined as 70% agreement. Sixteen experts participated in the study, and two rounds of the survey were completed. Twenty-one domains were considered relevant, including demographics, diagnosis, primary site, preoperative disease stage, previous tumor biopsy or surgery, preoperative tumor rupture, neoadjuvant therapy, surgical access, type of resection, completeness of resection, tumor margin assessment, locoregional tumor extension, organ resection, intraoperative tumor spillage, vascular involvement, lymph node sampling, estimated blood loss, intraoperative complications and interventions to address them, specimen names, and specimen orientation. We developed a SOR template for pediatric oncology surgery in LRSs. Consensus for all 21 domains and associated subdomains was achieved using a modified Delphi procedure.

Improving operative documentation in colorectal cancer surgery: synoptic notes pave the way forward.

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.

Evaluating narrative operative reports for endoscopic sinus surgery in a residency training program.

ObjectiveThe narrative operative report (NR) bears testimony to critical elements of patient care. Residents’ NRs also provide insights into their comprehension of the procedure. NR documentation is an informal element of surgical residency training but data regarding quality of such training are scant. We aim to evaluate the NR within a residency training program.MethodsThe quality of NRs for endoscopic sinus surgery (ESS) was evaluated through a retrospective analysis of 90 NRs for ESS. Thirty‐four elements that the attending surgeon regards as “critical” variables, or quality indicators (QIs), that should be documented, were studied to evaluate quality. A “performance metric (PM),” defined as the average percent of QIs dictated/total word count, was determined. Subgroup analysis by the level of training was additionally performed.ResultsSurgical indications, procedural steps, and immediate postoperative findings were accurately documented in 71%, 84%, and 82% of patients, respectively. The attending surgeon had the highest proportion of included key elements (89% ± 6.2%) followed by junior residents (87% ± 5.7%) and then senior residents (80% ± 14%) (P = .008). The attending surgeon also demonstrated the highest PM, followed by senior and then junior residents (P < .0001).ConclusionsThe quality of NRs was found to be high overall, but not “perfect” for either the attending or trainee surgeon. The PM among residents was expectedly lower than the attending surgeon. We propose that a synoptic reporting system that ensures inclusion of key elements may be helpful in training residents (and attendings) in creating comprehensive and efficient NRs.Level of Evidence3

Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass.

Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB). A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland-Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared. The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t=57.9, p<0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p<0.001) except for small bowel division details (p=0.530). Accuracy was significantly higher for SR than NR (94.2%±SD 4.31% vs. 53.6%±SD 9.82%, respectively, p<0.001). Rater agreement was excellent for both SR (0.11, 95% LOA -0.53 to 0.75) and NR (-0.26, 95% LOA -4.85 to 4.33) (p=0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55min±SD 1:26min and 4:50min±SD 0:50min, respectively, p=0.007). The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

Completeness of breast cancer operative reports in a community care setting

ObjectivesThe narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeon's case volume and years in practice on the completeness of these reports. Materials and methodsA standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally. Results772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness. ConclusionThe dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeon's volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.

Hospital-wide implementation of an electronic-workflow solution aiming to make surgical practice improvement easy.

In measuring quality of health-care delivery, digital infrastructure is essential. The aim at this tertiary centre was to create a hospital-wide workflow system that collected data prospectively as part of daily practice. In moving towards an electronic health record, a hospital-wide integrated workflow system was introduced in 2013, which electronically managed the perioperative patient journey while simultaneously facilitating surgical audit. Analysis of its implementation was carried out presenting early outcomes using general surgery as an example. Theatre-bookings (44 953) were made with compliance approaching 90% for all services. Of 7179 general surgical operations over 24 months, 5785 (80%) had an operation note created using the new system. Cumulative summation of uptake of synoptic operative reporting (SOR) for laparoscopic cholecystectomy (LC) was 81% with documentation being superior in terms of antibiotic use and steps to safe cholecystectomy (P < 0.001). A LC SOR took 4 min to complete (interquartile ranges 2-5 min, n = 425) and was immediately available on the day of surgery compared to narrative operative reports taking 2 days (interquartile ranges 1-5 days, n = 174) (P < 0.001). From July 2014 to November 2015, 557 (10%) complications were recorded for 5749 general surgical operations with 99% of complications being reviewed. The rapid and sustained uptake of both theatre-bookings and SOR likely reflect high end-user satisfaction with the system. Service metrics indicate a significant improvement in the time of delivery. The ability to seamlessly complete the audit cycle at an individual, department and hospital level has been achieved.

A5054 - Documentation of Quality of Care Data for Roux en Y Gastric Bypass: Comparison of Synoptic and Narrative Operative Reports

A5054 - Documentation of Quality of Care Data for Roux en Y Gastric Bypass: Comparison of Synoptic and Narrative Operative Reports

Quality of neck dissection operative reports

PurposeThe operative report is the official documentation of an operation and a key form of surgical communication. The objective of this study is to assess completeness of operative reports for neck dissections. MethodsThis is a retrospective review of narrative operative reports for neck dissections for head and neck squamous cell carcinoma. Forty-nine operative reports were provided by ten surgeons from seven academic institutions. Operative report completeness was expressed as a percentage of variables from a standardized checklist created by an expert panel. ResultsFor level 1 dissections, most reports identified critical structures, such as the marginal mandibular nerve (84%) and the submandibular gland (84%). Of the cases that involved submandibular gland excision, reports were deficient in identification of the lingual nerve (74%), hypoglossal nerve (58%) and submandibular duct (22%). For neck dissections involving levels 2, 3 and 4, most described identifying spinal accessory nerve (92%) and internal jugular vein (98%), whereas fewer described identification of carotid artery or vagus nerve (67%), ansa cervicalis (31%), or cervical rootlets (48%). For level 5 dissections, only 75% of reports reported identification of spinal accessory nerve. Sixty percent of reports provided some description of the removed lymph nodes, but there was no consistency in terminology or definitions. Overall completeness of all NORs was 64% (40%–79%, SD 9%). ConclusionsThere is heterogeneity and incompleteness in neck dissection operative reports across surgeons and institutions, despite being a crucial record of head and neck cancer treatment.

Synoptic operative reports enhance documentation of best practices for rectal cancer.

Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

Quality of narrative operative reports in pancreatic surgery

Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy. We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness. We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration. The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care.

The Computerized Synoptic Operative Report

As opposed to the traditional dictated report, the use of a computer-based synoptic operative report will mandate that the surgical resident have a better understanding of all facets of the procedure. A prospective study over a 10-month period. A 636-bed community teaching hospital. A total of 57 consecutive patients and 60 operative procedures for breast cancer. A total of 60 consecutive breast cancer narrative operative reports, dictated by the attending surgeon, were compared with synoptic computerized operative reports filled by an operating resident. It included a total of 36 items containing data on demographics, preoperative history, diagnostic evaluation, and precise intraoperative findings. The 2 types of reports were compared for overall completeness and for the completeness of individual items. Comparison of the narrative and synoptic reports showed that there was significant improvement in data completeness with the use of the synoptic report. The overall analysis showed that the synoptic operating report contained 94.7% of the preoperative and operative data, whereas the dictated operative report was able to capture only 66% of the data (P<.001). Eleven of 15 items in the general and preoperative sections of the dictated report and 6 of 21 items in the intraoperative section of the dictated report were underreported compared with those same items in the synoptic report (P=.004-.001). The computerized synoptic operative report is superior to the dictated report in the documentation of important preoperative and intraoperative data. Although checklists and templates are not new in medicine, the use of a synoptic operative report as a surgical educational tool is a novel concept. Each resident who participated in our study had to develop a better understanding of the operative procedure in order to complete a more accurate synoptic report.

Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control

The purpose of this study was to compare the completeness and reproducibility of data extracted from a standardized operative report (SOR) with the non-standardized operative report (NSOR). Between July and December 2003, operative data were collected from all laparoscopic cholecystectomy procedures performed at the Peter Lougheed Centre Hospital. A standardized format for dictating laparoscopic cholecystectomy operative reports was introduced on October 1, 2003. Non-standardized operative reports dictated in the first 3 months of the study period were compared with SORs dictated in the final 3 months. Two physicians independently extracted data from each operative report into a surgical database. During the study period, 221 cholecystectomy reports were analyzed (119 SOR and 102 NSOR). Completeness of data extraction for identifying variables (eg, patient name, age, and date of procedure) was similar in the 2 types of reports. However, most other operative and perioperative details were more completely reported in the SOR (95% to 100%) when compared to the NSOR (14% to 100% complete). Furthermore, interobserver agreement between 2 independent data extractors was better for the SOR than the NSOR (0.9972 vs 0.9809, P < .0001). Standardized operative reports result in more complete and reliably interpretable operative data compared with NSORs.