title: Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection.
abstract: BACKGROUND
  Electronic synoptic operative reports (E-SORs) have replaced dictated reports at many institutions, but whether E-SORs adequately document the components and findings of an operation has received limited study. This study assessed the reliability and completeness of E-SORs for pancreatic surgery developed at our institution.
  
  
  METHODS
  An attending surgeon and surgical fellow prospectively and independently completed an E-SOR after each of 112 major pancreatic resections (78 proximal, 29 distal, and 5 central) over a 10-month period (September 2008 to June 2009). Reliability was assessed by calculating the interobserver agreement between attending physician and fellow reports. Completeness was assessed by comparing E-SORs to a case-matched (surgeon and procedure) historical control of dictated reports, using a 39-item checklist developed through an internal and external query of 13 high-volume pancreatic surgeons.
  
  
  RESULTS
  Interobserver agreement between attending and fellow was moderate to very good for individual categorical E-SOR items (kappa = 0.65 to 1.00, p < 0.001 for all items). Compared with dictated reports, E-SORs had significantly higher completeness checklist scores (mean 88.8 +/- 5.4 vs 59.6 +/- 9.2 [maximum possible score, 100], p < 0.01) and were available in patients' electronic records in a significantly shorter interval of time (median 0.5 vs 5.8 days from case end, p < 0.01). The mean time taken to complete E-SORs was 4.0 +/- 1.6 minutes per case.
  
  
  CONCLUSIONS
  E-SORs for pancreatic surgery are reliable, complete in data collected, and rapidly available, all of which support their clinical implementation. The inherent strengths of E-SORs offer real promise of a new standard for operative reporting and health communication.
authors.affiliation: Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Jason
authors.initials: J
authors.lastname: Park
authors.forename: Venu G
authors.initials: VG
authors.lastname: Pillarisetty
authors.forename: Murray F
authors.initials: MF
authors.lastname: Brennan
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
authors.forename: Michael I
authors.initials: MI
authors.lastname: D'Angelica
authors.forename: Ronald P
authors.initials: RP
authors.lastname: Dematteo
authors.forename: Daniel
authors.initials: D
authors.lastname: G Coit
authors.forename: Maria
authors.initials: M
authors.lastname: Janakos
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Allen
mesh_terms: D004581:Electronics; D005568:Forms and Records Control / Q000458:organization & administration / Q000592:standards / Q000639:trends; D006801:Humans; D007432:Intraoperative Period; D016347:Medical Records Systems, Computerized / Q000458:organization & administration / Q000592:standards / Q000639:trends; D015588:Observer Variation; D010180:Pancreatectomy; D016577:Pancreaticoduodenectomy; D011446:Prospective Studies; D015203:Reproducibility of Results