title: Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports.
abstract: BACKGROUND
  Operative reports are a source of clinical data that can, for quality assurance purposes, be used to document the performance of processes that affect the care of surgical patients. We assessed the degree to which synoptic reports document operative quality indicators for colon cancer surgery.
  
  
  METHODS
  Two reviewers independently reviewed 80 prospectively collected synoptic colon cancer operative reports and a case-matched historical cohort of 80 dictated reports. Reviewers rated how well reports documented performance of quality of care indicators using two checklists of previously validated, colon cancer-specific quality measures. Interrater agreement and time to extract data were also recorded.
  
  
  RESULTS
  Synoptic reports had significantly higher overall scores on the quality indictors in comparison to dictated reports for both checklist 1 [mean adjusted score ± standard deviation 18.6 ± 1.3 vs. 9.2 ± 3.6, p < 0.01 (maximum score 38)] and checklist 2 [2.0 ± 0.3 vs. 1.3 ± 1.1, p < 0.01 (maximum score 3)]. Interrater agreement was significantly higher between synoptic reports for both checklists (data not shown). Data were extracted significantly more quickly from synoptic reports than dictated reports [mean time (minutes:seconds) ± standard deviation 2:32 ± 0:44 vs. 4:01 ± 1:14, p < 0.01].
  
  
  CONCLUSIONS
  Synoptic reports were associated with more complete documentation of quality indicators for colon cancer resection compared to dictated reports. Although synoptic reports may improve the documentation of quality of care data, further refinement may help to better document performance of quality measures and improve reporting standards.
authors.affiliation: Department of Surgery, University of Manitoba, Winnipeg, MB, Canada, reagan.maniar@gmail.com.
authors.forename: Reagan L
authors.initials: RL
authors.lastname: Maniar
authors.forename: David J
authors.initials: DJ
authors.lastname: Hochman
authors.forename: Debrah A
authors.initials: DA
authors.lastname: Wirtzfeld
authors.forename: Andrew M
authors.initials: AM
authors.lastname: McKay
authors.forename: Clifford S
authors.initials: CS
authors.lastname: Yaffe
authors.forename: Benson
authors.initials: B
authors.lastname: Yip
authors.forename: Richard
authors.initials: R
authors.lastname: Silverman
authors.forename: Jason
authors.initials: J
authors.lastname: Park
mesh_terms: D016022:Case-Control Studies; D003110:Colonic Neoplasms / Q000175:diagnosis / Q000601:surgery*; D003625:Data Collection / Q000379:methods*; D013505:Digestive System Surgical Procedures; D004282:Documentation; D005500:Follow-Up Studies; D006801:Humans; D016347:Medical Records Systems, Computerized; D011379:Prognosis; D011446:Prospective Studies; D019984:Quality Indicators, Health Care