Completeness of dictated operative reports in breast cancer--the case for synoptic reporting

J Surg Oncol. 2012 Jul 1;106(1):79-83. doi: 10.1002/jso.23031. Epub 2012 Jan 10.


Background: Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic reporting using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was to determine the current completeness of dictated operative reports for breast cancer surgery.

Methods: An iterative, consensus-based approach to determining elements of a proposed synoptic surgical operative report identified critical elements. We then evaluated the dictated operative reports of 100 consecutive breast cancer patients for completeness of these elements.

Results: Details regarding presentation and diagnosis were frequently incomplete (84%). Among patients undergoing mastectomy, the potential for breast conservation was partially described in only 60%. Only 41% had data regarding intra-operative margin assessment during breast conservation surgery. In axillary lymph node dissections, 92% of patients had complete data about preservation of nerves, yet only 14% of reports contained complete information regarding sentinel lymph node biopsy. Closure was partially described in 91%.

Conclusions: The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system, which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.

MeSH terms

  • Adult
  • Aged
  • Breast Neoplasms / diagnosis*
  • Breast Neoplasms / pathology
  • Breast Neoplasms / surgery*
  • Canada
  • Female
  • Humans
  • Lymph Node Excision
  • Mammaplasty
  • Mastectomy* / adverse effects
  • Mastectomy* / methods
  • Medical Records / standards*
  • Medical Records / statistics & numerical data*
  • Medical Records Systems, Computerized
  • Middle Aged
  • Postoperative Complications / prevention & control
  • Quality Improvement* / trends
  • Retrospective Studies
  • Sentinel Lymph Node Biopsy