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Effectiveness of Synoptic Reports in Enhancing Documentation Practices in Pediatric Surgical Oncology: A Pilot
Abdelhafeez H Abdelhafeez1, Derek Harrison2, Amos Loh3
1Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, Golisano Children's Hospital, Rochester, New York, USA.
Background:
Precision in surgical documentation is crucial for minimizing communication discrepancies and preventing errors in patient care. Synoptic operative reports (SR) offer greater accuracy than narrative operative reports (NR); however, their adoption in pediatric surgical oncology remains limited. To enhance documentation practices, a standardized operative report was developed. This study assessed its effectiveness through a two-phase approach. Phase 1 retrospectively evaluated the completeness of NR for pediatric patients undergoing solid tumor resection at major pediatric cancer centers across diverse regions and resource settings. In Phase 2, following the implementation of SR at these institutions, we prospectively analyzed the completeness of operative documentation.
Methods:
We conducted a multi-regional pre- and post-implementation study in five pediatric oncology reference centers. Eligible cases included primary malignant solid tumor resections. Pulmonary or other metastatic resections, benign tumors, and biopsies were excluded. Phase 1 consisted of a retrospective review of NR over 6 months in 2023. Phase 2 prospectively evaluated SR over 6 months post-implementation.
Results:
A total of 165 operative reports were analyzed (73 NR, 92 SR). SR demonstrated significantly higher completeness in documenting key intraoperative elements, including completeness of resection, locoregional spread, tumor spillage, vascular involvement, lymph node sampling, and specimen naming. End-user surveys (n = 17) showed that 94% agreed SR captured key intraoperative details and improved documentation clarity. Seventy-seven percent agreed SR supported treatment decision-making, 71% agreed they enhanced communication during multidisciplinary team (MDT) meetings, and 82% agreed SR improved workflow efficiency. The mean System Usability Scale score was 81.1, reflecting excellent usability.
Conclusions:
SR enhances completeness, data extraction, and communication compared to NR. Their integration into pediatric oncology practice may improve both documentation quality and multidisciplinary care.
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