Completeness of dictated operative reports in breast cancer—the case for synoptic reporting

Donahoe, Laura; Bennett, Sean; Temple, Walley J.; Hilchie‐Pye, Andrea; Dabbs, Kelly; MacIntosh, Ethel; Porter, Geoff

doi:10.1002/jso.23031

Cited by 46 publications

(25 citation statements)

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“…Their quality audit reinforced these perceptions, as the 40 Roux‐en‐Y gastric bypass NRs they analyzed contained only 62% ± 6.6% of the variables deemed necessary for inclusion. This lack of completeness within NRs was also found in NRs for pancreatic surgery (72.5% completeness for pancreaticoduodenectomy), breast surgery (66% completeness), and upper limb surgery (71.1% completeness) . That fact that our study found a higher average QI inclusion rate (85%) compared to these other studies may reflect the greater emphasis placed on documentation at our institution.…”

Section: Discussionsupporting

confidence: 59%

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

Wheeler

Miglani

Deep

et al. 2019

Laryngoscope Investig Oto

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Objective The 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. Methods The 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. Results Surgical 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). Conclusions The 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 Evidence 3

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Section: Discussionsupporting

confidence: 59%

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

Wheeler

Miglani

Deep

et al. 2019

Laryngoscope Investig Oto

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“…Several studies report that SRs provide more complete information than the NRs. 4,[23][24][25][26][27] In other specialties, par ticularly in pathology, synoptic reporting has been widely embraced, which has improved interdisciplinary com munication and led to more effective coordination of clinical care for individual patients. [28][29][30] There is wide acceptance of SRs by clinicians who prefer the readability of SRs over NRs.…”

Section: Discussionmentioning

confidence: 99%

“…[28][29][30] There is wide acceptance of SRs by clinicians who prefer the readability of SRs over NRs. [27][28][29][30] Further structured synoptic reporting results promote quality by standardizing the reporting processes among patients and institutions. Several jurisdictions mandate the use of synoptic pathology reports as a performance indicator.…”

Section: Discussionmentioning

confidence: 99%

Quality of narrative operative reports in pancreatic surgery

et al. 2013

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Background: 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. Methods: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. Results: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. Conclusion: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. Conclusion :Les NO sont souvent incomplètes et leur qualité laisse à désirer. Des éléments importants, dont le protocole opératoire et les données oncologiques, étaient souvent manquants. Ainsi, les NO constituent une source inadéquate de données en ce qui concerne les IQ. Il faudra encourager la mise au point et l'utilisation d'autres types de rapports, dont des synopsis opératoires standardisés, pour mieux documenter les soins chirurgicaux prodigués et pour en évaluer la qualité. Q uality improvement is an important component of health care systems. Quality in health care can be evaluated in terms of the structures, processes and outcomes of care.

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“…They describe the course of the operation as well as any abnormal findings in the surgical process. Template-based and structured methods exist for recording the operative note (DeOrio, 2002), and in many cases have been shown to increase the completeness of surgical information (Park et al, 2010;Gur et al, 2011;Donahoe et al, 2012). The use of natural language, however, is still preferred for its expressive power.…”

Section: Introductionmentioning

confidence: 99%

Proceedings of BioNLP 2014

2014

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IntroductionThe first day of the BioNLP 2014 workshop continues following the course set by the first ACL workshop on Natural Language Processing in the Biomedical Domain that was held in 2002: BioNLP 2014 provides a venue for exploring challenges and techniques in processing biomedical language and brings together researchers from computational linguistics and biomedical informatics. The submissions to the first day of 2014 workshop organized by SIGBioMed were traditionally very strong and continued demonstrating the considerable breadth of research in biomedical language processing. The 2014 workshop has accepted 12 full and short papers for oral presentations and 7 posters. The first day of the workshop features a keynote that expands the scope of BioNLP beyond its already remarkable breadth The second day of the workshop features a paper submitted to the special track on NLP approaches for assessment of clinical conditions. Kathleen C. Fraser presents the featured talk on using statistical parsing to detect agrammatic aphasia. The track organizers, Thamar Solorio and Yang Liu, serve as discussants.The second day further features an exciting panel that brings together organizers of several shared tasks in biomedical information retrieval and natural language processing. The panel introduces the workshop participants to the long-standing and relatively new community-wide challenges in biomedical and clinical language processing. It also provides an opportunity to discuss the future of the shared tasks in this domain. AcknowledgmentsAs always, we are profoundly grateful to the authors who chose BioNLP as venue for presenting their innovative research. The authors' willingness to share their work through BioNLP consistently makes the workshop noteworthy among the increasing numbers of available venues. We are equally indebted to the program committee members (listed elsewhere in this volume) who produced at least three thorough reviews per paper on a tight review schedule and with an admirable level of insight.iii AbstractZoonotic viruses, viruses that are transmittable between animals and humans, represent emerging or re-emerging pathogens that pose significant public health threats throughout the world. It is therefore crucial to advance current surveillance mechanisms for these viruses through outlets such as phylogeography. Phylogeographic techniques may be applied to trace the origins and geographical distribution of these viruses using sequence and location data, which are often obtained from publicly available databases such as GenBank. Despite the abundance of zoonotic viral sequence data in GenBank records, phylogeographic analysis of these viruses is greatly limited by the lack of adequate geographic metadata. Although more detailed information may often be found in the related articles referenced in these records, manual extraction of this information presents a severe bottleneck. In this work, we propose an automated system for extracting this information using Natural Language Processing (NLP)...

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Completeness of dictated operative reports in breast cancer—the case for synoptic reporting

Abstract: The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system, which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.

Cited by 46 publications

References 10 publications

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

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

Quality of narrative operative reports in pancreatic surgery

Proceedings of BioNLP 2014

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