Electronic synoptic operative reporting for thyroid surgery using an electronic data management system: potential for prospective multicenter data collection

Ann Surg Oncol. 2011 Mar;18(3):762-6. doi: 10.1245/s10434-010-1361-0. Epub 2010 Sep 30.

Abstract

Background: Electronic synoptic operative reports ensure systematic documentation of all critical components and findings during complex surgical procedures. Thyroid surgery lends itself to synoptic reporting, because there are a predefined number of essential intraoperative events and findings that every endocrine surgeon invariably records.

Methods: An electronic web-based form (e-form) was designed and implemented to record operative data in a synoptic structure for thyroid surgery. The e-form was implemented as a pilot study from January 2008 to October 2009 for use by three attending surgeons.

Results: During this period, 514 e-forms were completed with 100% compliance, which recorded data from 384 total thyroidectomies and 130 thyroid lobectomies. All users found the e-form to be easy to use, comprehensive, and took less than 5 min to complete.

Conclusions: The main advantages of a web-based e-form for synoptic recording of thyroid surgery are that it is user-friendly and easy to complete, yet comprehensive. Because it is based on a system available across institutions, it can be used as a minimum dataset and could be considered a national and international standard for wider use, especially if endorsed by the American or International Association for Endocrine Surgeons.

Publication types

  • Multicenter Study

MeSH terms

  • Humans
  • Medical Records Systems, Computerized*
  • Pilot Projects
  • Prognosis
  • Prospective Studies
  • Retrospective Studies
  • Survival Rate
  • Thyroid Neoplasms / surgery*
  • Thyroidectomy*