Petrushkevich Alisiya, Livingston Eliza, Davidson Jacob, Wilson Claire A, Lam Jennifer Y, Wilejto Marta, Seemann Natashia M
Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
Division of Paediatric Surgery, London Health Sciences Centre, London, ON, Canada.
J Pediatr Surg. 2025 Apr;60(4):162186. doi: 10.1016/j.jpedsurg.2025.162186. Epub 2025 Jan 23.
The purpose of this study was to audit paediatric surgical oncology dictations to evaluate completeness and ease of data collection and provide a baseline measurement for the implementation of synoptic operative reports (SORs) in a tertiary care setting.
An audit tool based on Children's Oncology Group (COG) protocols was created to assess the completeness of surgical and tumour-specific data within operative reports. Audited cases included four paediatric tumours of interest (Germ Cell, Wilms, Neuroblastoma, and Hepatoblastoma) between 2010 and 2023.
Overall, 71 audits were performed, the majority being Wilms Tumour cases (45.1 %), followed by Neuroblastoma (29.6 %), Germ Cell (18.3 %), and Hepatoblastoma (7.0 %). The average percentage of complete data for operative reports was low; the mean completeness of general oncological information for all tumour types was 66.0 %, and tumour-specific details were 42.0 %. Ovarian Germ Cell Tumour had the highest average percentage of complete data (65.9 %), followed by Wilms Tumour (58.7 %), Testicular Germ Cell Tumour (43.0 %), Neuroblastoma (15.0 %), and Hepatoblastoma (9.5 %). The median data collection time was 6.0 min per audit. The median time from the operation to the transcription of the report was 1.0 days (interquartile range (IQR): 1.0-7.0).
Narrative operative reports have inadequate completeness, especially concerning tumour-specific factors, which are often essential in accurate diagnosis, and in guiding treatment for children with cancer. SORs could be a solution and aid in the completeness and accessibility of data use.
Retrospective review.
LEVEL OF EVIDENCE (I-V): IV.
本研究旨在审核儿科外科肿瘤学记录，以评估数据收集的完整性和便捷性，并为三级医疗机构实施概要手术报告（SOR）提供基线测量。
创建了一个基于儿童肿瘤学组（COG）方案的审核工具，以评估手术报告中手术和肿瘤特异性数据的完整性。审核的病例包括2010年至2023年间四种感兴趣的儿科肿瘤（生殖细胞肿瘤、肾母细胞瘤、神经母细胞瘤和肝母细胞瘤）。
总体而言，共进行了71次审核，其中大多数是肾母细胞瘤病例（45.1%），其次是神经母细胞瘤（29.6%）、生殖细胞肿瘤（18.3%）和肝母细胞瘤（7.0%）。手术报告的完整数据平均百分比很低；所有肿瘤类型的一般肿瘤学信息的平均完整性为66.0%，肿瘤特异性细节为42.0%。卵巢生殖细胞肿瘤的完整数据平均百分比最高（65.9%），其次是肾母细胞瘤（58.7%）、睾丸生殖细胞肿瘤（43.0%）、神经母细胞瘤（15.0%）和肝母细胞瘤（9.5%）。每次审核的数据收集时间中位数为6.0分钟。从手术到报告转录的时间中位数为1.0天（四分位间距（IQR）：1.0 - 7.0）。
叙述性手术报告的完整性不足，尤其是关于肿瘤特异性因素，而这些因素在准确诊断以及指导癌症儿童治疗方面通常至关重要。SOR可能是一种解决方案，有助于提高数据使用的完整性和可及性。
回顾性研究。
证据水平（I - V）：IV。
