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

• Published in: Journal of surgical oncology Vol. 106; no. 1; pp. 79 - 83
• Main Authors: Donahoe, Laura, Bennett, Sean, Temple, Walley, Hilchie-Pye, Andrea, Dabbs, Kelly, MacIntosh, Ethel, Porter, Geoff
• Format: Journal Article
• Language: English
• Published: Hoboken Wiley Subscription Services, Inc., A Wiley Company 01.07.2012
• Subjects: Adult; Aged; breast cancer; Breast Neoplasms - diagnosis; Breast Neoplasms - pathology; Breast Neoplasms - surgery; Canada; documentation; Female; Humans; Lymph Node Excision; Mammaplasty; Mastectomy - adverse effects; Mastectomy - methods; Medical Records - standards; Medical Records - statistics & numerical data; Medical Records Systems, Computerized; Middle Aged; Postoperative Complications - prevention & control; Quality Improvement - trends; Retrospective Studies; Sentinel Lymph Node Biopsy; surgery; Canada
• ISSN: 0022-4790; 1096-9098
• DOI: 10.1002/jso.23031

Background Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic reporting using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was to determine the current completeness of dictated operative reports for breast cancer surgery. Methods An iterative, consensus‐based approach to determining elements of a proposed synoptic surgical operative report identified critical elements. We then evaluated the dictated operative reports of 100 consecutive breast cancer patients for completeness of these elements. Results Details regarding presentation and diagnosis were frequently incomplete (84%). Among patients undergoing mastectomy, the potential for breast conservation was partially described in only 60%. Only 41% had data regarding intra‐operative margin assessment during breast conservation surgery. In axillary lymph node dissections, 92% of patients had complete data about preservation of nerves, yet only 14% of reports contained complete information regarding sentinel lymph node biopsy. Closure was partially described in 91%. Conclusions 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. J. Surg. Oncol. 2012; 106:79–83. © 2012 Wiley Periodicals, Inc.