Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system.
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%).


CONCLUSIONS
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.
Chambers
Anthony J
AJ
Department of Surgery, Division of Surgical Oncology, University of Calgary and the Tom Baker Cancer Centre, Calgary, Alberta, Canada.
Pasieka
Janice L
JL
Temple
Walley J
WJ
D006801:Humans; D020407:Internet; D007432:Intraoperative Period; D016347:Medical Records Systems, Computerized; D010280:Parathyroid Glands / Q000473:pathology; D011379:Prognosis; D012009:Recurrent Laryngeal Nerve / Q000473:pathology; D013536:Suture Techniques; D013637:Tape Recording; D013964:Thyroid Neoplasms / Q000098:blood supply / Q000473:pathology* / Q000601:surgery*; D013965:Thyroidectomy / Q000379:methods / Q000706:statistics & numerical data*; D014584:User-Computer Interface