Pathology reports provided reliable and readily accessible records of surgical procedures performed in women with breast cancer.
OBJECTIVE
Extracting complete and accurate records of surgical procedures from case-notes is time consuming and laborious. We compared the completeness and time taken to extract data on surgical procedures from case-notes and from pathology reports.


METHODS
Information on surgical procedures was extracted from pathology reports and hospital case-notes for 111 women with breast cancer in three centers. The time taken to perform this task was recorded. Surgical procedures were classified into diagnostic and therapeutic procedures, and analysis was performed to determine the completeness and accuracy of the documentation of the procedures.


RESULTS
The average time taken to extract relevant information from the pathology reports (3.0 minutes) was one-fifth that for the case-notes (14.4 minutes). The case-notes documented slightly fewer procedures than the pathology records: 94 vs. 108 diagnostic and 108 vs. 110 therapeutic procedures, respectively. Of the 219 therapeutic and diagnostic surgical procedures recorded by both data sources, for 216 procedures there was exact agreement as to the specific type of procedure performed.


CONCLUSIONS
Extraction of information on surgical procedures is faster from pathology records than from case-notes. The level of agreement for the specific type of procedure performed is excellent and, if anything, the pathology records are more complete than the case-notes.
Gathani
T
T
Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Headington, Oxford OX3 7LF, UK. toral.gathani@ceu.ox.ac.uk
Green
J
J
Reeves
G
G
Beral
V
V
D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D016208:Databases, Factual; D004282:Documentation; D005260:Female; D006801:Humans; D016247:Information Storage and Retrieval / Q000379:methods*; D008198:Lymph Nodes / Q000601:surgery; D008408:Mastectomy / Q000706:statistics & numerical data; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D010340:Pathology, Surgical / Q000706:statistics & numerical data*; D006113:United Kingdom