Electronic synoptic operative reporting for thyroid surgery using an electronic data management system: potential for prospective multicenter data collection.
BACKGROUND
Electronic synoptic operative reports ensure systematic documentation of all critical components and findings during complex surgical procedures. Thyroid surgery lends itself to synoptic reporting, because there are a predefined number of essential intraoperative events and findings that every endocrine surgeon invariably records.


METHODS
An electronic web-based form (e-form) was designed and implemented to record operative data in a synoptic structure for thyroid surgery. The e-form was implemented as a pilot study from January 2008 to October 2009 for use by three attending surgeons.


RESULTS
During this period, 514 e-forms were completed with 100% compliance, which recorded data from 384 total thyroidectomies and 130 thyroid lobectomies. All users found the e-form to be easy to use, comprehensive, and took less than 5 min to complete.


CONCLUSIONS
The main advantages of a web-based e-form for synoptic recording of thyroid surgery are that it is user-friendly and easy to complete, yet comprehensive. Because it is based on a system available across institutions, it can be used as a minimum dataset and could be considered a national and international standard for wider use, especially if endorsed by the American or International Association for Endocrine Surgeons.
Iyer
N Gopalakrishna
NG
Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Nixon
Iain J
IJ
Palmer
Frank
F
Ganly
Ian
I
Patel
Snehal G
SG
Shaha
Ashok R
AR
D006801:Humans; D016347:Medical Records Systems, Computerized; D010865:Pilot Projects; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate; D013964:Thyroid Neoplasms / Q000601:surgery*; D013965:Thyroidectomy