Quality of narrative operative reports in pancreatic surgery.
BACKGROUND
Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy.


METHODS
We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness.


RESULTS
We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration.


CONCLUSIONS
The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care.
The Division of General Surgery, University Health Network, University of Toronto, Toronto, Ont.
Meagan E
ME
Wiebe
Lakhbir
L
Sandhu
Julie L
JL
Takata
Erin D
ED
Kennedy
Nancy N
NN
Baxter
Anna R
AR
Gagliardi
David R
DR
Urbach
Alice C
AC
Wei
D004282:Documentation / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D033262:Narration; D016577:Pancreaticoduodenectomy; D017064:Process Assessment, Health Care; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies