Synoptic operative reports enhance documentation of best practices for rectal cancer

Maniar, Reagan L.; Sytnik, Peter; Wirtzfeld, Debrah; Hochman, David; McKay, Andrew; Yip, Benson; Hebbard, Pamela; Park, Jason

doi:10.1002/jso.24039

Cited by 42 publications

(64 citation statements)

References 18 publications

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“…In varied settings, including thyroid cancer and pancreatic cancer, synoptic reporting has been examined by international studies and validated as a method for capturing clinical data and improving patient outcomes. [29][30][31] Technological advances have made ultrasonography more accessible, and surgeon-directed assessments are now significantly more likely to drive interventions. 32,33 In fact, the lack of standardized reporting is driving the increased uptake of ultrasonog raphy among surgeons owing to the varied quality of reports, and this trend is accelerating.…”

Section: Discussionmentioning

confidence: 99%

The utility of thyroid ultrasonography in the management of thyroid nodules

Gamme

Parrington

Wiebe

et al. 2017

CJS

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Background: Ultrasonography for thyroid nodules is one of the most common imaging tests performed in the general population. Details from ultrasound reports guide biopsies and surgery. This study quantifies the completeness of these reports based on Thyroid Imaging and Reporting System (TI-RADS) criteria and considers their utility in predicting malignant disease. Methods:We retrospectively reviewed ultrasound reports for 329 thyroidectomy patients and extracted data elements using the TI-RADS criteria: nodule size, echogenicity, margins, vascularity, solid/cystic composition and the presence or absence of microcalcifications and the halo sign. We assessed the reports to determine whether individual or multiple criteria were associated with malignancy.Results: More than 97% of reports document nodule size; however, more than 90% of the reports noted only 3 or fewer of the 6 remaining TI-RADS criteria. The presence of microcalcifications was the most sensitive marker of malignancy (> 90%), whereas the documentation of irregular margins was the most specific indicator of malignancy (88%). Overall it was clear that microcalcifications, hypoechogenicity, irregular margins and solid nodules were significantly more likely to be found in malignant neoplasms; their absence predicted benign disease. Because so few reports consistently documented all criteria, the overall ability of thyroid ultrasonography to discriminate between lowerand higher-risk nodules is limited. Conclusion:Although the accuracy of thyroid ultrasonography is good, few ultrasound reports contain the necessary information, as defined by TI-RADS, to predict malignancy and guide management. When reported, microcalcifications and/or irregular margins are the best predictors of malignancy.Contexte : L'échographie des nodules thyroïdiens est l'une des épreuves d'imagerie les plus souvent effectuées dans la population générale. Les détails fournis par l'échographie guident les biopsies et la chirurgie. Cette étude quantifie l'exhaustivité des rapports d'échographie selon les critères TI-RADS (Thyroid Imaging and Reporting System) et en mesure l'utilité pour prédire les cancers.Méthodes : Nous avons passé en revue de façon rétrospective les rapports d'échographie de 329 patients ayant subi une thyroïdectomie et nous en avons extrait les éléments sous l'angle des critères TI-RADS : taille des nodules, échogénicité, marges, vascularité, composition solide c. kystique, présence ou absence de microcalcifications et signe du halo. Nous avons évalué les rapports afin de déterminer si certains critères individuels ou multiples pouvaient être associés au cancer.Résultats : Plus de 97 % des rapports mentionnent la taille des nodules; mais, plus de 90 % des rapports ne font état que de 3 critères ou moins sur les 6 autres critères TI-RADS. La présence de microcalcifications a été le marqueur tumoral le plus sensible (> 90 %), tandis que la présence de marges irrégulières a été le marqueur tumoral le plus spécifique (88 %). Dans l'ensemble, les microcalcifications, l'...

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Section: Discussionmentioning

confidence: 99%

The utility of thyroid ultrasonography in the management of thyroid nodules

Gamme

Parrington

Wiebe

et al. 2017

CJS

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“…Additionally, the use of prompts including drop‐down selection in electronic operation notes can encourage completeness as they serve as timely reminders for commonly omitted information, especially in those fields found to be deficient in our study. Indeed, synoptic reports have been associated with more reliable and complete reports . Such improvement in quality of medical records in addition to the subsequent improvement in patient care has seen a shift from handwritten to electronic discharge summaries in many institutions .…”

Section: Discussionmentioning

confidence: 99%

Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

Nzenza

Manning

Ngweso

et al. 2017

ANZ Journal of Surgery

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The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.

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“…Review of the literature on synoptic operative reports demonstrates significant advantages over standard dictations for rectal cancer and breast. [3][4][5] It is electronic and web based with dropdown menus; this form of operative report was associated with more complete and reliable documentation. 6 What is unclear from the literature is whether it was associated with actual improved performance, which was the main problem we addressed in our study.…”

Section: Surgical Protocol Violations In Children With Renal Tumors Pmentioning

confidence: 99%

“…suggest another evidence‐based tool to improve surgical quality, the synoptic operative report. Review of the literature on synoptic operative reports demonstrates significant advantages over standard dictations for rectal cancer and breast . It is electronic and web based with dropdown menus; this form of operative report was associated with more complete and reliable documentation .…”

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confidence: 99%

Reply to: Synoptic operative reports for quality improvement in pediatric cancer care

Ehrlich

2018

Pediatric Blood & Cancer

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Synoptic operative reports enhance documentation of best practices for rectal cancer

Cited by 42 publications

References 18 publications

The utility of thyroid ultrasonography in the management of thyroid nodules

The utility of thyroid ultrasonography in the management of thyroid nodules

Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

Reply to: Synoptic operative reports for quality improvement in pediatric cancer care

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