Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system

Background

Documentation of thyroidectomy is performed traditionally by surgeon-dictated operative reports (DORs). A Web-based system that generates a synoptic report (WebSMR) for thyroidectomy was developed. The purpose of this study was to assess the completeness of documentation in WebSMR compared with DOR.

Methods

In all, 271 DORs and 133 WebSMR were reviewed for the documentation of (1) prognostic information for the MACIS score calculation; (2) key anatomic structures such as recurrent laryngeal nerve (RLN) and parathyroid glands; and (3) nonessential information such as middle thyroid vein (MTV) ligation and sutures used for closure.

Results

Overall DOR documented presence/absence of invasion in 27%, completeness of resection in only 3%, and tumor size in 29%, whereas these were recorded in 100% of WEBSMR (P < .001). The MACIS scores could not be calculated from any DOR, whereas WebSMRs have a MACIS calculator incorporated in the software. Although subtle differences were found in reporting anatomic structures depending on training, DORs were good at reporting the status of the RLNs (>95%) and parathyroids (>83%) compared with 100% in WebSMRs. DOR routinely included nonessential information; MTV (80%) and sutures used for closure (93% to 98%).

Conclusion

Use of the WebSMRs was superior to DORs in documenting key prognostic and anatomic findings without nonessential information, and it produced a superior document that can aid in postoperative care.