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Evaluating narrative operative reports for endoscopic sinus surgery in a residency training program.

Shannon C Wheeler1, Amar Miglani2, Nicholas L Deep2

  • 1University of Arizona College of Medicine Phoenix Phoenix Arizona U.S.A.

Laryngoscope Investigative Otolaryngology
|June 26, 2019
PubMed
Summary

The quality of narrative operative reports (NRs) for endoscopic sinus surgery was high overall. A synoptic reporting system could improve NR quality in surgical residency training.

Keywords:
Narrative reportendoscopic sinus surgerymedical educationoperative reportquality indicators

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Area of Science:

  • Otolaryngology
  • Surgical Education
  • Health Informatics

Background:

  • Narrative operative reports (NRs) are crucial for patient care and assessing surgical residents' understanding.
  • The quality of NR documentation in surgical residency training is often informal and lacks comprehensive evaluation.
  • Data on the quality of NR training are scarce, necessitating objective assessment.

Purpose of the Study:

  • To evaluate the quality of narrative operative reports (NRs) generated within a surgical residency program.
  • To assess the documentation of critical quality indicators (QIs) in NRs for endoscopic sinus surgery (ESS).
  • To analyze the performance metric (PM) of NRs based on the inclusion of QIs and correlate it with the level of surgical training.

Main Methods:

  • Retrospective analysis of 90 NRs for endoscopic sinus surgery (ESS).
  • Evaluation of 34 critical quality indicators (QIs) identified by attending surgeons.
  • Calculation of a performance metric (PM) defined as the average percentage of QIs documented per total word count.
  • Subgroup analysis of NRs based on the level of resident training (junior vs. senior).

Main Results:

  • Surgical indications, procedural steps, and immediate postoperative findings were documented in 71%, 84%, and 82% of NRs, respectively.
  • Attending surgeons demonstrated the highest proportion of included QIs (89%) and the highest PM.
  • Senior residents (80% QIs) and junior residents (87% QIs) showed progressively lower QI inclusion and PM compared to attending surgeons (P < .0001).

Conclusions:

  • The overall quality of NRs for ESS is high but not perfect for attending surgeons or residents.
  • Resident performance metrics (PM) were lower than attending surgeons, indicating room for improvement in NR documentation.
  • Implementing a synoptic reporting system could enhance the inclusion of critical elements, improving NR comprehensiveness and efficiency for both residents and attendings.