An accurate surgical report is critical to patient care, impacting aftercare and outcomes. No matter how well-executed a surgical procedure is, an incomplete or inaccurate record can lead to faulty decision-making by follow-up medical teams. In addition, data included in a surgical report may help to improve processes and identify problem areas within your facility and to explain treatment decisions should questions arise after the fact. The content of those reports may even fuel medical research.
Ensuring Accurate Surgical Reports
Clearly, minimizing surgical report errors is a top priority. To ensure accurate reporting:
- Employ systems that encourage surgeons to complete reports immediately after surgery. Naturally, important information will be clearer in the surgeon’s mind right after the procedure than hours or days later—all the more so if he or she has conducted additional similar procedures in the interim. Making it as easy as possible for the surgeon to record critical data while it’s fresh will reduce the likelihood of omissions or misremembered details.
- Enter data only once. Historically, surgical notes are dictated and then the surgical report transcribed either in-house or by an outside contractor. Other systems require that handwritten notes be transferred into an electronic system. No matter how well-trained and careful the professionals transcribing or entering that data are, mistakes happen. Each transfer your system requires creates another opportunity to introduce errors.
- Follow a clear and consistent format. Free-form dictation means that each surgeon’s reports may be a bit different, and a single surgeon may even vary formats or tack a piece of missed information on at the end. In the event that the surgeon leaves out something important or misspeaks, that error is far less likely to be noted in a free-form report than it would be if data were entered into designated fields.
- Control data entry where possible. Messy handwriting, unclear speech, an uncommon manner of phrasing or even a typographical error can create confusion in the record. Employing a system that offers selections in formats such as drop-downs and check boxes eliminate the possibility of misspellings, odd pronunciations or unfamiliar terminology.
Synoptic reporting addresses each of these areas of concern. Because entering data into a synoptic reporting template is straightforward and time-efficient, it is easier and more intuitive for surgeons to take a few minutes to complete the surgical report immediately after the procedure, rather than allowing reports to pile up until the end of the day or the end of the week.
That direct data entry also eliminates the step of transferring handwritten notes or transcribing dictation, eliminating an opportunity for error. In addition, when the entry is completed by the person with firsthand knowledge of the procedure, any error that might occur in the entry of data is much more likely to be recognized and corrected immediately—particularly when clearly-marked fields ensure that all relevant data is entered in the appropriate location and in appropriate terms.
Photo credit: Phalinn Ooi