Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
Br J Surg. 2013 Feb;100(3):426-32. doi: 10.1002/bjs.8994. Epub 2012 Dec 19.
The operative report contains critical information for patient care, serves an educational purpose and is an important source for surgical research. Recent studies demonstrate that operative reports are unstructured and lack vital components. The accuracy of the operative notes has never been assessed. The aim of this study was to analyse the accuracy of operative reports by comparing notes with intraoperative observer-derived findings regarding adhesions and adhesiolysis-related complications.
The incidence of adhesions and adhesiolysis-induced injury were scored from the reports by a researcher blinded to operative findings obtained prospectively by direct observation. In addition, factors influencing correct reporting were analysed, including sex, surgical experience, delay in dictation, and the gradual introduction of a new report template with a focus on describing operative findings rather than actions taken.
A total of 755 consecutive operative reports were analysed. Sensitivity and specificity for the incidence of adhesions was 85·1 and 72·4 per cent respectively. Six of 43 inadvertent enterotomies, and 17 of 48 other organ injuries, had not been reported. All missed bowel injuries were found in reports written in the old template. A median delay in dictating of 3 (range 1-226) working days was found for 56 reports (7·4 per cent). Documentation of inadvertent enterotomies was missing more often in delayed reports (2 of 3 versus 4 of 40 reports dictated with no delay; P = 0·022).
The sensitivity and specificity of operative reports noting adhesions and adhesiolysis were low. One in seven enterotomies was not reported. Effort should be put into teaching timely, meaningful, structured and accurate reporting of surgical procedures.
手术记录包含了对患者治疗至关重要的信息，具有教育意义，也是外科研究的重要资料。最近的研究表明，手术记录缺乏结构且重要信息缺失。手术记录的准确性从未被评估过。本研究旨在通过比较手术记录与术中观察者记录的粘连情况和粘连松解相关并发症，分析手术记录的准确性。
由一名对术中观察到的手术结果不知情的研究者，根据报告对粘连的发生率和粘连松解引起的损伤进行评分。此外，还分析了影响正确报告的因素，包括性别、手术经验、记录延迟以及逐步引入新的报告模板，重点是描述手术发现而不是所采取的操作。
共分析了 755 份连续的手术报告。粘连发生率的敏感性和特异性分别为 85.1%和 72.4%。43 例无意肠切开术中有 6 例，48 例其他器官损伤中有 17 例未报告。所有漏诊的肠损伤均发生在旧模板报告中。56 份报告（7.4%）记录的中位记录延迟为 3（范围 1-226）个工作日。在延迟报告中，无意肠切开术的记录缺失更为常见（3 例中的 2 例与无延迟报告中的 40 例中的 4 例；P=0.022）。
手术记录中粘连和粘连松解的敏感性和特异性较低。有 1/7 的肠切开术未被报告。应该努力教授及时、有意义、有结构和准确的手术报告。
