Synoptic operative reporting for laparoscopic cholecystectomy and pancreaticoduodenectomy: A multi institutional pilot study evaluating completeness and surgeon perceptions

腹腔镜胆囊切除术和胰十二指肠切除术的手术记录概要:一项评估完整性和外科医生认知的多中心试点研究

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Abstract

BACKGROUND: Synoptic operative reports (SOR) are more accurate than dictated operative reports (DOR) in a few single institution experiences. We sought to examine the completeness of SOR for laparoscopic cholecystectomy (LC) and pancreaticoduodenectomy (PD) in a multi institutional pilot study. METHODS: Six institutions participated in SOR submission via a web-based survey. One institution collected DOR and case matched historical dictated operative reports (HOR) for subset analysis. A checklist evaluated completeness of all reports. A post-survey assessed participant opinions. RESULTS: 40 PD SORs were 98.5% complete and 35 LC SORs were 99.7% complete. Single institution subset analysis respective percent complete were: 11 PD SORs 99%, DORs 70% and HORs 74% and 14 LC SORs 99.7%, DORs 76%, and HORs 75%. Post-survey results yielded 10 PD and 24 LC responses. An overwhelming majority agreed that SOR were easy to use and would prefer to use SOR compared to DOR. CONCLUSION: SOR are more complete than both study associated DOR and HOR. The majority of surgeons indicated their preference for SOR and their willingness to use them.

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