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.
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.
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%).
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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- Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989.Surgery. 1993; 114: 1050-1058
- Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients.World J Surg. 2002; 26: 879-885
- Follow up approaches in thyroid cancer: a risk adapted paradigm.Endocrinol Metab Clin North Am. 2008; 37: 419-435
- Outcomes of patients with differentiated thyroid carcinoma following initial therapy.Thyroid. 2006; 16: 1229-1242
- Treatment of thyroid cancer based on risk groups.J Surg Oncol. 2006; 94: 683-691
- Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.Thyroid. 2006; 16: 109-142
- The computer synoptic operative report–a leap forward in the science of surgery.Ann Surg Oncol. 2004; 11: 941-947
- Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports.AMIA Annu Symp Proc. 2005; : 425-429
- Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents.Am Surg. 2005; 71: 627-632
- The dictated operative note: important but is it being taught?.J Am Coll Surg. 2000; 190: 639-640
- Surgical templates for orthopedic operative reports.Orthopedics. 2002; 25: 639-642
- Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control.Surgery. 2007; 141: 708-714
- Prognostic scoring systems in patients with follicular thyroid cancer: a comparison of different staging systems in predicting the patient outcome.Thyroid. 2004; 14: 453-458
- Staging systems for papillary thyroid carcinoma: a review and comparison.Ann Surg. 2007; 245: 366-378
Accepted: September 25, 2009
© 2009 Published by Elsevier Inc. All rights reserved.