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.
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Article info
Publication history
Accepted:
September 25,
2009
Identification
Copyright
© 2009 Published by Elsevier Inc. All rights reserved.
