Ashley Vergis1, Shannon E Stogryn2, Michael J Mullan2, Krista Hardy2. 1. University of Manitoba, Department of Surgery, Winnipeg, Manitoba, Canada. Electronic address: avergis@sbgh.mb.ca. 2. University of Manitoba, Department of Surgery, Winnipeg, Manitoba, Canada.
Abstract
BACKGROUND: Operative reporting is the foundation of surgical communication. The quality indicators (QIs) contained in these reports can be used to document the performance of processes that affect patient care and may afford quality assurance with improvement in healthcare. OBJECTIVES: We assessed the degree to which the electronic synoptic report (SR) documents the operative QIs compared with narrative reports (NR) for Roux-en-Y gastric bypass (RYGB). The time to report availability on patient chart was also identified as a secondary measure. SETTING: Academic center, public hospital, Canada. METHODS: A total of 40 prospectively collected RYGB synoptic reports and 40 case-matched historical NRs were compared against checklist QIs that were established by a national Delphi process. These checklist QIs are validated and have high interrater agreement at our institution. Time from dictation to report availability on patient chart was measured. RESULTS: SR had a mean completion of 99.7% (±standard deviation [SD] 1.3%) compared with 64.0% (±SD 6.3%) for NR (t = 36.0, P<.0001). All subsections of SR were>99% complete and significantly higher than NR (P<.001). The mean time from NR dictation to report availability was 4.14 days (SD±3.17, range 0-10 d). All SRs were in the operative area after the procedure and were available immediately. CONCLUSION: The RYGB synoptic report is superior to the narrative report for inclusion of accepted quality indicators and time to availability. Important elements, including process of care, demographic characteristics, and anatomic-related data, were often missing from the NR. SR is a promising method for improving documentation for RYGB.
BACKGROUND: Operative reporting is the foundation of surgical communication. The quality indicators (QIs) contained in these reports can be used to document the performance of processes that affect patient care and may afford quality assurance with improvement in healthcare. OBJECTIVES: We assessed the degree to which the electronic synoptic report (SR) documents the operative QIs compared with narrative reports (NR) for Roux-en-Y gastric bypass (RYGB). The time to report availability on patient chart was also identified as a secondary measure. SETTING: Academic center, public hospital, Canada. METHODS: A total of 40 prospectively collected RYGB synoptic reports and 40 case-matched historical NRs were compared against checklist QIs that were established by a national Delphi process. These checklist QIs are validated and have high interrater agreement at our institution. Time from dictation to report availability on patient chart was measured. RESULTS:SR had a mean completion of 99.7% (±standard deviation [SD] 1.3%) compared with 64.0% (±SD 6.3%) for NR (t = 36.0, P<.0001). All subsections of SR were>99% complete and significantly higher than NR (P<.001). The mean time from NR dictation to report availability was 4.14 days (SD±3.17, range 0-10 d). All SRs were in the operative area after the procedure and were available immediately. CONCLUSION: The RYGB synoptic report is superior to the narrative report for inclusion of accepted quality indicators and time to availability. Important elements, including process of care, demographic characteristics, and anatomic-related data, were often missing from the NR. SR is a promising method for improving documentation for RYGB.
Authors: Shannon E Stogryn; Krista Hardy; Michael J Mullan; Jason Park; Christopher Andrew; Ashley Vergis Journal: Surg Endosc Date: 2017-09-15 Impact factor: 4.584
Authors: Garrett G R J Johnson; Harminder Singh; Ashley Vergis; Jason Park; Olivia Hershorn; David Hochman; Ramzi M Helewa Journal: Surg Endosc Date: 2021-06-08 Impact factor: 4.584
Authors: Shannon C Wheeler; Amar Miglani; Nicholas L Deep; Marlene E Girardo; Michael Hinni; Devyani Lal Journal: Laryngoscope Investig Otolaryngol Date: 2019-04-23