Robertson Reagan L, Vergis Ashley
From the *Department of Surgery, University of Manitoba, Winnipeg, Canada.
Am Surg. 2020 Mar 1;86(3):184-189.
Operative reports can be used to evaluate quality of care indicators in surgical patients. This study evaluated documentation of preoperative and intraoperative quality of care indicators for rectal cancer surgery in synoptic reports and traditional dictated reports. Two surgeons independently reviewed 40 prospectively collected synoptic operative reports from rectal cancer cases and a case-matched historical cohort of 40 dictated reports. Rectal cancer-specific quality measures were scored in both report groups using two separate, previously validated checklists. Synoptic reports had significantly higher overall scores on both checklists 1 (mean adjusted score ± SD 76 ± 4 41 ± 19, < 0.01) and 2 (54 ± 3 24 ± 11, < 0.01; maximum score of 100 for both checklists). Synoptic reports scored significantly higher in reporting preoperative and intraoperative care indicators. Data were extracted quickly from synoptic reports (mean 3:46 6:21, minutes:seconds to complete checklists, < 0.05). Synoptic reports are associated with accurate documentation of quality of care data for rectal cancer surgery. Refining the synoptic templates used will further enhance the collection of quality indicators and reporting in complex oncologic procedures.
手术报告可用于评估外科手术患者的护理质量指标。本研究评估了概要报告和传统口述报告中直肠癌手术术前和术中护理质量指标的记录情况。两名外科医生独立审查了40份前瞻性收集的直肠癌病例概要手术报告以及40份口述报告的病例匹配历史队列。使用两份单独的、先前经验证的检查表对两个报告组中的直肠癌特异性质量指标进行评分。概要报告在检查表1（平均调整后得分±标准差 76±4对41±19，P<0.01）和检查表2（54±3对24±11，P<0.01；两份检查表的最高分均为100）上的总体得分均显著更高。概要报告在报告术前和术中护理指标方面得分显著更高。从概要报告中提取数据的速度很快（平均3:46对6:21，分钟:秒，完成检查表，P<0.05）。概要报告与直肠癌手术护理质量数据的准确记录相关。完善所使用的概要模板将进一步加强复杂肿瘤手术中质量指标的收集和报告。
