Abstract
OBJECTIVE
The purpose of this study is to assess the degree to which synoptic reports (SRs) and dictated reports (DRs) document elements of the Ovarian Cancer Pan-Canadian Standards Data Elements (OCPCDE) checklist, and to compare their completeness. Analysis of dictated versus synoptic reporting has never been performed for suspected epithelial ovarian cancer (EOC) based on literature review at the time of data collection (1-12).
METHODS
A retrospective chart review was performed including 254 charts of women 18 years or older, from 2012 to 2017, undergoing surgery for suspected EOC. Charts from five gynecologic oncologists, at a single tertiary care centre were used. The OCPCDE checklist was used to evaluate their completeness. Comparison of completeness between SRs and DRs was done using linear regression with a fixed effect of surgeon to account for intraclass correlation.
RESULTS
The data showed that SRs included 20.1% more data elements than DRs. Data elements that may be perceived as being more critical were more likely to be documented in SRs. Residual disease data was documented in 51.7% DR versus 99.1% of SR. Descriptive data upon entering the abdomen was more frequently documented in DRs.
CONCLUSION
This study shows that synoptic reporting includes more data elements deemed important by the OCPCDE checklist authors for suspected epithelial ovarian cancer surgery in our centre. We would recommend continuation of SRs in our department, and implementation of synoptic reporting in other gynecologic oncology centres where surgery for suspected epithelial ovarian cancer is performed.
TY - JOUR
T1 - A comparison of synoptic reports and dictated reports to enhance and standardize surgical documentation and quality of care in epithelial ovarian cancer.
AU - Shirley,Jenna,
AU - Lambert,Pascal,
AU - Nachtigal,Mark W,
AU - Altman,Alon D,
Y1 - 2023/01/12/
PY - 2022/11/19/received
PY - 2023/01/01/revised
PY - 2023/01/02/accepted
PY - 2023/1/15/pubmed
PY - 2023/3/15/medline
PY - 2023/1/14/entrez
KW - Cancer
KW - Ovarian
KW - Surgical dictation
KW - Synoptic reporting
SP - 54
EP - 58
JF - Gynecologic oncology
JO - Gynecol Oncol
VL - 170
N2 - OBJECTIVE: The purpose of this study is to assess the degree to which synoptic reports (SRs) and dictated reports (DRs) document elements of the Ovarian Cancer Pan-Canadian Standards Data Elements (OCPCDE) checklist, and to compare their completeness. Analysis of dictated versus synoptic reporting has never been performed for suspected epithelial ovarian cancer (EOC) based on literature review at the time of data collection (1-12). METHODS: A retrospective chart review was performed including 254 charts of women 18 years or older, from 2012 to 2017, undergoing surgery for suspected EOC. Charts from five gynecologic oncologists, at a single tertiary care centre were used. The OCPCDE checklist was used to evaluate their completeness. Comparison of completeness between SRs and DRs was done using linear regression with a fixed effect of surgeon to account for intraclass correlation. RESULTS: The data showed that SRs included 20.1% more data elements than DRs. Data elements that may be perceived as being more critical were more likely to be documented in SRs. Residual disease data was documented in 51.7% DR versus 99.1% of SR. Descriptive data upon entering the abdomen was more frequently documented in DRs. CONCLUSION: This study shows that synoptic reporting includes more data elements deemed important by the OCPCDE checklist authors for suspected epithelial ovarian cancer surgery in our centre. We would recommend continuation of SRs in our department, and implementation of synoptic reporting in other gynecologic oncology centres where surgery for suspected epithelial ovarian cancer is performed.
SN - 1095-6859
UR - https://www.unboundmedicine.com/medline/citation/36640651/A_comparison_of_synoptic_reports_and_dictated_reports_to_enhance_and_standardize_surgical_documentation_and_quality_of_care_in_epithelial_ovarian_cancer_
DB - PRIME
DP - Unbound Medicine
ER -
