Related Experiment Video
Updated: May 25, 2026

Enhanced Communication of Tumor Margins Using 3D Scanning and Mapping
Published on: December 15, 2023
Completeness of dictated operative reports in breast cancer--the case for synoptic reporting
Laura Donahoe1, Sean Bennett, Walley Temple
1Queen Elizabeth II Health Sciences Centre/Dalhousie University, Halifax, Nova Scotia, Canada. laura.donahoe@dal.ca
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.
Related Concept Videos
Types of Reports III: Telephone and Verbal Reports
Here's an overview of each type:
Telephone Orders
Types of Reports I: Hand-off Report
Following are the key components and categories of hand-off reports:
Purpose and Process:
Data Reporting and Recording
SBAR I: Understanding the Concept
Standardized methods of communication have been developed to ensure that information is...
Types of Reports II: Incident or Occurrence Report
Purposes:
In the healthcare industry, reports play a crucial role in documenting incidents within an agency. The primary objective of these reports is to ensure patient safety, uphold the...
Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...