Electronic synoptic operative reporting: Assessing the reliability and completeness of synoptic reports for pancreatic resection Journal Article
| Authors: | Park, J.; Pillarisetty, V. G.; Brennan, M. F.; Jarnagin, W. R.; D'Angelica, M. I.; DeMatteo, R. P.; Coit, D. G.; Janakos, M.; Allen, P. J. |
| Article Title: | Electronic synoptic operative reporting: Assessing the reliability and completeness of synoptic reports for pancreatic resection |
| Abstract: | BACKGROUND: Electronic synoptic operative reports (E-SORs) have replaced dictated reports at many institutions, but whether E-SORs adequately document the components and findings of an operation has received limited study. This study assessed the reliability and completeness of E-SORs for pancreatic surgery developed at our institution. STUDY DESIGN: An attending surgeon and surgical fellow prospectively and independently completed an E-SOR after each of 112 major pancreatic resections (78 proximal, 29 distal, and 5 central) over a 10-month period (September 2008 to June 2009). Reliability was assessed by calculating the interobserver agreement between attending physician and fellow reports. Completeness was assessed by comparing E-SORs to a case-matched (surgeon and procedure) historical control of dictated reports, using a 39-item checklist developed through an internal and external query of 13 high-volume pancreatic surgeons. RESULTS: Interobserver agreement between attending and fellow was moderate to very good for individual categorical E-SOR items (kappa = 0.65 to 1.00, p < 0.001 for all items). Compared with dictated reports, E-SORs had significantly higher completeness checklist scores (mean 88.8 ± 5.4 vs 59.6 ± 9.2 [maximum possible score, 100], p < 0.01) and were available in patients' electronic records in a significantly shorter interval of time (median 0.5 vs 5.8 days from case end, p < 0.01). The mean time taken to complete E-SORs was 4.0 ± 1.6 minutes per case. CONCLUSIONS: E-SORs for pancreatic surgery are reliable, complete in data collected, and rapidly available, all of which support their clinical implementation. The inherent strengths of E-SORs offer real promise of a new standard for operative reporting and health communication. © 2010 American College of Surgeons. |
| Keywords: | treatment outcome; surgical technique; pancreas resection; prospective study; prospective studies; pancreaticoduodenectomy; reproducibility of results; observer variation; information processing; electronic medical record; electronic data interchange; correlation coefficient; medical education; intraoperative period; surgeon; medical record; medical records systems, computerized; scoring system; pancreatectomy; physician; reliability; medical information system; operating room; intraclass correlation coefficient; forms and records control; kappa statistics; checklist; cis; clinical information system; e-sor; ebl; electronic synoptic operative report; estimated blood loss; icc; memorial sloan-kettering cancer center; mskcc; or; pd; electronic synoptic operative reporting; mandatory reporting; electronics |
| Journal Title: | Journal of the American College of Surgeons |
| Volume: | 211 |
| Issue: | 3 |
| ISSN: | 1072-7515 |
| Publisher: | Elsevier Science, Inc. |
| Date Published: | 2010-09-01 |
| Start Page: | 308 |
| End Page: | 315 |
| Language: | English |
| DOI: | 10.1016/j.jamcollsurg.2010.05.008 |
| PUBMED: | 20800186 |
| PROVIDER: | scopus |
| DOI/URL: | |
| Notes: | --- - "Cited By (since 1996): 2" - "Export Date: 20 April 2011" - "CODEN: JACSE" - "Source: Scopus" |
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1059Brennan -
637DeMatteo -
6Park -
29
Pillarisetty -
501Allen -
903Jarnagin -
777D'Angelica -
542Coit -
4
Janakos
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