Video Documentation in Thyroidectomy and an Evaluation of Operative Notes

Area of Science:

• Surgical Documentation
• Medical Informatics
• Quality Improvement in Healthcare

Background:

• Accurate surgical operation notes are vital for post-operative care, research, and medico-legal documentation.
• Existing studies highlight deficiencies and inaccuracies in traditional operative notes.
• Methods to improve the objectivity of surgical documentation are actively being explored.

Purpose of the Study:

• To evaluate the completeness of thyroidectomy operative notes at a tertiary care center.
• To assess the adequacy of video documentation by comparing it with written operative notes.

Main Methods:

• Retrospective review of 385 thyroidectomy operative notes (2010-2020).
• Comparison of written notes with video recordings of 15 thyroidectomies.
• Completeness scoring based on a predefined item checklist.
• Statistical analysis using independent samples t-test and one-way ANOVA.

Main Results:

• Retrospective review showed a mean completeness score of 54.47% for written thyroidectomy notes.
• Video-documented operative records achieved a significantly higher mean completeness score (83.86%) compared to written notes (47.53%) (p <0.001).

Conclusions:

• Video documentation offers a substantial improvement in the completeness and accuracy of thyroidectomy operative notes.
• Video recording serves as a valuable tool for surgical education, skills training, and research.
• Implementing video documentation can enhance the overall quality of surgical record-keeping.