Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery.

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.