Advancement in the quality of operative documentation: A systematic review and meta-analysis of synoptic versus narrative operative reporting

Stogryn, Shannon; Hardy, Krista; Abou‐Setta, Ahmed M; Clouston, Kathleen; Metcalfe, Jennifer; Vergis, Ashley

doi:10.1016/j.amjsurg.2019.05.003

Cited by 33 publications

(46 citation statements)

References 26 publications

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“…In a systematic literature review, Stogryn et al found that synoptic operative reports were associated with completeness and shortened completion time. 20 Our study found that trainees dictated one-third to three-fourths of operative reports. Synoptic operative reports, which are required for CoC accreditation after 2020, provide a framework of required elements which could enhance surgical education, regardless of level of training.…”

Section: Discussionmentioning

confidence: 59%

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery

Reeves

Mudgway

Lee

et al. 2020

The American Surgeon™

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To improve the quality of cancer operations, the American College of Surgeons published Operative Standards for Cancer Surgery, which has been incorporated into Commission on Cancer (CoC) accreditation requirements. We sought to determine if compliance with operative standards was associated with technical surgical outcomes. Oncologic operative reports from 2017 at a CoC and non-CoC institution were examined for documentation of Operative Standards essential steps. Lymph node (LN) yield for lung and colon cases and re-excision rates for breast cases were recorded. Correct documentation was poor for colon, breast, and lung cases with numerous elements documented in <10% of operative reports at both centers. For lung cases, there was no significant difference in meeting ≥10 LN benchmark or average LN yield between the 2 institutions. For colon cases, average lymph node yield was lower in the non-CoC facility, but there was no significant difference in meeting ≥12 LN benchmark. For breast cases, re-excision rates were similar in both programs. Many essential steps in Operative Standards were poorly documented in operative reports, regardless of CoC status. Achieving benchmark technical surgical outcomes was not associated with documented compliance with these standards. Whether improved documentation leads to better surgical outcomes requires further investigation.

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Section: Discussionmentioning

confidence: 59%

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery

Reeves

Mudgway

Lee

et al. 2020

The American Surgeon™

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“…This reflects advances in other areas of medicine such as pathology and radiology where synoptic reporting has improved communication and reduced reporting delays. Two recent meta-analyses by Stogryn et al and Eryigit et al compared synoptic versus narrative operative reports across a wide range of surgical disciplines [ 11 , 48 ]. Both including publications from Harvey and Thomson dealing with LC [ 23 , 31 ].…”

Section: Discussionmentioning

confidence: 99%

“…There is increasing realization of the value of synoptic operative notes which are templated and procedure specific [ 11 ]. Inclusion of archived (and retrievable) video recordings and intra-operative photographs may enhance reporting, not just of surgical procedures but in many areas of medicine [ 12 – 14 ].…”

Section: Introductionmentioning

confidence: 99%

It’s time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review

et al. 2022

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Background Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. Methods A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one “ideal” laparoscopic operative report template following international input from the World Society of Emergency Surgery board. Results A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. Conclusion This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals’ medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

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“…[382][383][384][385] Synoptic reporting methods were developed as a result of the lack of essential informations in the narrative operative reports in other surgical disciplines. [386][387][388][389][390][391][392][393][394][395][396][397][398][399][400][401][402] The synoptic operative report generally improves completeness and consistency in surgical documentation compared with the traditional narrative operative report, suggesting its incorporation into surgical practice. ESGO has approved a template for ovarian cancer operative reports.…”

Section: Society Statementmentioning

confidence: 99%

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

Concin¹,

Abu‐Rustum

Ataseven

et al. 2021

Int J Gynecol Cancer

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BackgroundQuality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.ObjectiveIn order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.MethodsQIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.ResultsTwenty-nine structural, process and outcome indicators were defined. QIs 1–5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25–29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

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Advancement in the quality of operative documentation: A systematic review and meta-analysis of synoptic versus narrative operative reporting

Cited by 33 publications

References 26 publications

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery

It’s time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

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