Abstract
BACKGROUND: Operative reports (OP-Rs) are essential for communication among healthcare providers. They require accuracy and completeness to serve as a quality indicator of patient care. Objective assessment of primary total knee replacement (TKR) OP-Rs has never been reported. Therefore, a standardized benchmark for assessment and factors affecting the completeness of TKR OP-Rs needs to be evaluated. AIM: To evaluate the completeness rate of primary TKR OP-Rs in a teaching hospital and to assess the factors affecting completeness. METHODS: A retrospective review of 58 consecutive primary TKR OP-Rs in a tertiary teaching hospital were included in this study. We used document analysis to review the OP-Rs against a standardized list of six subsets of mandatory variables. The correlation between the percentage of completeness and the specific variables was determined. RESULTS: After analyzing 58 cases, we found that the time to documentation was 1.5 hours. Out of the 52 mandatory variables, a median of 30 variables were documented yielding a completeness of 58%. Administrative, procedural, exposure, and implant variables were documented the most often, whereas clinical and process variables were most frequently left uncompleted. The documentation of the operative maneuver was variable. There was no association between the completeness of the reports and the time to documentation, documenter level, complication rate, operative duration, or length of hospital stay. CONCLUSION: Multiple variables were left undocumented on the unstructured primary TKR OP-Rs. The completeness percentage will likely improve after the implementation of a standardized structured OP-R.