title: Synoptic operative reports for spinal cord injury patients as a tool for data quality.
abstract: The advent of synoptic operative reports has revolutionized how clinical data are captured at the time of care. In this article, an electronic synoptic operative report for spinal cord injury was implemented using interoperable standards, HL7 and Systematized Nomenclature of Medicine-Clinical Terms. Subjects (N = 10) recruited for a pilot study completed recruitment and feedback questionnaires, and produced both an electronic synoptic operative report for spinal cord injury report and a dictated narrative operative report for an actual patient case. Results indicated heterogeneity by subjects in access and use of electronic sources of patient data. Feedback questionnaire results confirmed that subjects were comfortable using both methods for data entry of operative reports, and that some were unable to find the diagnosis terms they needed in electronic synoptic operative report for spinal cord injury. Data quality improved. Electronic synoptic operative report for spinal cord injury reports were more complete (95.26%) than dictated (80%) for all subjects. An accuracy assessment, which considered usability for secondary data use, was conducted and the electronic synoptic operative report for spinal cord injury was demonstrated to improve accuracy.
authors.affiliation: Dalhousie University, Canada grace.paterson@dal.ca.
authors.forename: Grace I
authors.initials: GI
authors.lastname: Paterson
authors.affiliation: Dalhousie University, Canada.
authors.forename: Sean
authors.initials: S
authors.lastname: Christie
authors.affiliation: Dalhousie University, Canada.
authors.forename: Wilfred
authors.initials: W
authors.lastname: Bonney
authors.affiliation: Dalhousie University, Canada.
authors.forename: Ginette
authors.initials: G
authors.lastname: Thibault-Halman
mesh_terms: D000328:Adult; D002170:Canada; D000068598:Data Accuracy; D004282:Documentation / Q000379:methods / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D000069471:Neurosurgeons; D010361:Patients / Q000523:psychology*; D010865:Pilot Projects; D012985:Software Design; D013119:Spinal Cord Injuries / Q000601:surgery*; D011795:Surveys and Questionnaires
keywords: data quality; interoperability; spine surgery; standards; synoptic operative report