Bariatric operative reporting: Quality assessment and perceptions among bariatric surgeons

Abstract

Background: The quality of narrative operative notes is poor. No investigation has previously addressed operative reporting specifically in bariatric surgery.

Objectives: To evaluate surgeons' perceptions of the quality of operative reporting in bariatric surgery and compare this to an audit of Roux-en-Y gastric bypass (RYGB) narrative reports using validated quality indicators.

Setting: University hospital, Canada.

Methods: A Web-based survey was distributed to bariatric surgeons across Canada. Perceptions regarding the quality of reporting were gathered using a Likert scale (modified Structured Assessment Format for Evaluating Operative Reports) and free text fields. Forty RYGB narrative reports were analyzed against established quality indicators and compared to respondent's perceptions based on themes.

Results: Twenty-four of 34 bariatric surgeons (71%) completed the survey. The most commonly performed procedures were RYGB and sleeve gastrectomy (96% and 100%, respectively). Currently, 70.8% perform a traditional narrative report. The average Structured Assessment Format for Evaluating Operative Reports score for narrative dictations by bariatric surgeons was neutral (27.9/40). The lowest scoring items were the "description of indications" (2.9/5) and "succinctness" (3.3/5). Opinions reflected a need for an immediately generated, standardized, template-based report to improve the quality and accessibility of operative documentation. The quality audit reinforced respondents' perceptions. Reports included only 62.0%±6.6% of quality indicators, with the lowest scoring areas being "patient details," "preoperative events," and "postoperative details" (41.1%, 32.4%, and 31.7%, respectively).

Conclusion: This survey revealed a perception of mediocre quality of narrative dictations. This was reinforced by an audit of RYGB operative reports. Future investigations should focus on improving this form of operative communication.

Keywords: Bariatric surgery; Operative reporting; Quality.