title: Completeness of dictated operative reports in breast cancer--the case for synoptic reporting.
abstract: BACKGROUND
  Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic reporting using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was to determine the current completeness of dictated operative reports for breast cancer surgery.
  
  
  METHODS
  An iterative, consensus-based approach to determining elements of a proposed synoptic surgical operative report identified critical elements. We then evaluated the dictated operative reports of 100 consecutive breast cancer patients for completeness of these elements.
  
  
  RESULTS
  Details regarding presentation and diagnosis were frequently incomplete (84%). Among patients undergoing mastectomy, the potential for breast conservation was partially described in only 60%. Only 41% had data regarding intra-operative margin assessment during breast conservation surgery. In axillary lymph node dissections, 92% of patients had complete data about preservation of nerves, yet only 14% of reports contained complete information regarding sentinel lymph node biopsy. Closure was partially described in 91%.
  
  
  CONCLUSIONS
  The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system, which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.
authors.affiliation: Queen Elizabeth II Health Sciences Centre/Dalhousie University, Halifax, Nova Scotia, Canada. laura.donahoe@dal.ca
authors.forename: Laura
authors.initials: L
authors.lastname: Donahoe
authors.forename: Sean
authors.initials: S
authors.lastname: Bennett
authors.forename: Walley
authors.initials: W
authors.lastname: Temple
authors.forename: Andrea
authors.initials: A
authors.lastname: Hilchie-Pye
authors.forename: Kelly
authors.initials: K
authors.lastname: Dabbs
authors.forename: Ethel
authors.initials: E
authors.lastname: Macintosh
authors.forename: Geoff
authors.initials: G
authors.lastname: Porter
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D002170:Canada; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D016462:Mammaplasty; D008408:Mastectomy / Q000009:adverse effects / Q000379:methods; D008499:Medical Records / Q000592:standards* / Q000706:statistics & numerical data*; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control; D058996:Quality Improvement / Q000639:trends; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy