title: Quality of neck dissection operative reports.
abstract: OBJECTIVE
  The operative report is the official documentation of an operation and a key form of surgical communication. The objective of this study is to assess completeness of operative reports for neck dissections.
  
  
  METHODS
  This is a retrospective review of narrative operative reports for neck dissections for head and neck squamous cell carcinoma. Forty-nine operative reports were provided by ten surgeons from seven academic institutions. Operative report completeness was expressed as a percentage of variables from a standardized checklist created by an expert panel.
  
  
  RESULTS
  For level 1 dissections, most reports identified critical structures, such as the marginal mandibular nerve (84%) and the submandibular gland (84%). Of the cases that involved submandibular gland excision, reports were deficient in identification of the lingual nerve (74%), hypoglossal nerve (58%) and submandibular duct (22%). For neck dissections involving levels 2, 3 and 4, most described identifying spinal accessory nerve (92%) and internal jugular vein (98%), whereas fewer described identification of carotid artery or vagus nerve (67%), ansa cervicalis (31%), or cervical rootlets (48%). For level 5 dissections, only 75% of reports reported identification of spinal accessory nerve. Sixty percent of reports provided some description of the removed lymph nodes, but there was no consistency in terminology or definitions. Overall completeness of all NORs was 64% (40%-79%, SD 9%).
  
  
  CONCLUSIONS
  There is heterogeneity and incompleteness in neck dissection operative reports across surgeons and institutions, despite being a crucial record of head and neck cancer treatment.
authors.affiliation: Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, 5841 S. Maryland Avenue, MC, Chicago, IL, USA. Electronic address: nocon@surgery.wisc.edu.
authors.forename: Cheryl C
authors.initials: CC
authors.lastname: Nocon
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, 1305 York Avenue, 5th floor, New York, NY. Electronic address: mac2093@med.cornell.edu.
authors.forename: Marc A
authors.initials: MA
authors.lastname: Cohen
authors.affiliation: Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, 5841 S. Maryland Avenue, MC, Chicago, IL, USA. Electronic address: alexander.langerman@vanderbilt.edu.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Langerman
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D000068598:Data Accuracy; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D008499:Medical Records; D037981:Neck Dissection; D010818:Practice Patterns, Physicians'; D015203:Reproducibility of Results; D012189:Retrospective Studies