Uptake and impact of synoptic reporting in a community care setting.

BACKGROUND: Breast cancer surgeries have traditionally been documented in narrative reports. Narrative reports have been shown to be incomplete. Synoptic reports utilize standardized templates to record data and have emerged as an alternative to narrative reports. This study evaluates the uptake and impact of synoptic reporting for breast cancer surgery in a community care setting. METHODS: A retrospective review of operative reports documenting breast cancer surgeries over a consecutive 3-year period. RESULTS: 772 narrative reports and 158 synoptic reports were reviewed. Synoptic reports were associated with a higher degree of overall completeness (60% vs 45%) when compared to narrative reports. 6 out of 7 surgeons that produced at least 5 synoptic and 5 narrative reports had increases in completeness with use of synoptic reporting. CONCLUSIONS: Use of synoptic reporting improves breast cancer operative report completeness and decreases superfluous content when compared to narrative reports. While synoptic report uptake during the study period was suboptimal there exists several means by which it can be improved, including investment in information technology infrastructure and emphasis on stakeholder engagement.

Completeness of breast cancer operative reports in a community care setting.

OBJECTIVES: The narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeon's case volume and years in practice on the completeness of these reports. MATERIALS AND METHODS: A standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally. RESULTS: 772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness. CONCLUSION: The dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeon's volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.