Completeness of operative reports for rectal cancer surgery

Am J Surg. 2020 Jul;220(1):165-169. doi: 10.1016/j.amjsurg.2019.09.036. Epub 2019 Sep 28.


Introduction: Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation. We sought to determine whether operative reports contain the key elements recommended by the National Accreditation Program for Rectal Cancer.

Methods: Rectal cancer operative reports from June-December 2018 were submitted from ten hospitals in Michigan. These reports were analyzed to identify key elements in the synoptic operative template and assessed for completeness.

Results: In total, 110 operative reports were reviewed. Thirty-one (28%) reports contained all 24 elements; all of these reports used a synoptic template. Overall, 62 (56%) reports used a synoptic template and 48 (44%) did not. Using a synoptic template significantly improved documentation, as these reports contained 92% of required elements, compared to 39% for narrative reports (p < 0.001).

Conclusions/discussion: Narrative operative reports inconsistently document rectal cancer resection. This study provides evidence that synoptic reporting will improve quality of documentation for rectal cancer surgery.

Keywords: NAPRC; Operative note completeness; Rectal cancer quality; Synoptic operative report.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Humans
  • Medical Records Systems, Computerized / standards*
  • Michigan
  • Proctectomy / statistics & numerical data*
  • Prospective Studies
  • Quality Improvement*
  • ROC Curve
  • Rectal Neoplasms / surgery*