Completeness of breast cancer operative reports in a community care setting

The narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeon's case volume and years in practice on the completeness of these reports.

A standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally.

772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness.

The dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeon's volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.