3 Reasons Justifying Synoptic Data in Surgical Operative Reports for Orthopedic Surgeons

John T. Mattson, MD, Consultant for mTuitive and Orthopedic Surgeon -   Print  |
For over 60 years, originating with the Dictaphone Belt recorder, voice dictation has been the standard for producing operative reports. Although the technology has changed (including the advent of speech recognition software), very little of the content has been improved or altered; we've changed how we put the information in, but not the way we pull the information out.

Complications

Driven by regulations and compliance, the basic elements of surgical data which are routinely included in operative reports consist of the date of the procedure, the names of the surgeon and assistant(s), what procedure was performed, diagnosis and the type of anesthesia. Typically, surgeons do not enjoy dictating since the majority of the content and details are repetitious and boring. The ennui of dictating often results in abbreviated descriptions of procedural details that, while meeting mandated requirements, leave much to be desired in completeness and clarity.

Upon review, either by the surgeon or a subsequent provider, these insufficient operative reports often lead to confusion or incomplete understanding of exactly what was done during the procedure. In addition, dictation in paragraph format requires the use of transcription — which is costly and time-consuming. The interpretive process of transcription leads to delays in coding and billing the operative procedure as well as confusion as to which codes apply, resulting in improper reimbursement and incorrect information entering the patient's medical record. Adding to the surgeon's burden is the requirement of reviewing and signing an operative report as well as the frequent need to confer with the business office about the proper codes and charges.

Compliance entities have had little to say about the contents of the operative procedure description, giving rise to significant variances among surgeons' completeness when describing the details of the surgical procedure. As a surgeon who has had the experience of reviewing many transcribed operative reports for medical-legal and medical staff committee purposes, I've noticed the significant deviation in the amount of information that can be extracted from an individual report. The deficiencies of paragraph style reporting will be magnified by the increasing transparency and scrutiny enabled by more sophisticated electronic health records.

Advantages of synoptic reports


1. Ensures proper coding and comprehensive operative reports. These numerous deficiencies are resolved through the use of computerized synoptic reports. "Synoptic reports" are those that capture discrete structured data using limited options, Boolean questions and/or a checklist to ensure completeness and uniformity. Multiple studies, like this one, have proven that surgical checklists drastically reduce errors while greatly improving results by encouraging completeness of care and reporting. Electronic reports can be created rapidly and easily and are available immediately for information and billing purposes. Even better, using intelligent synoptic reporting programs ensures inclusion of proper coding in these comprehensive operative reports.

2. Avoids redundancies.
The surgeon avoids the redundancy of dictated reports and produces a document that complies with various standards and protocols while eliminating the need for transcription. This results in financial savings for the facility as well as producing a comprehensively documented synoptic report that will add considerable value when reviewed later.

3. Acts as a research tool.
Synoptic reports can also be used for data mining for research purposes, quality indicator tracking or any other situation where statistical evaluations are indicated. The clear layout and formatting of the report makes it easy to understand by any other medical providers or health professionals while promoting the inclusion and creation of a universal, standard operative report.

Electronically based synoptic operative reports will be the future along with paperless electronic health records. Companies are developing electronic operative report solutions, including the mTuitive in Centerville, Mass., with whom I've worked to develop a system called OpNote. I believe such systems will be the paradigm of the future and hasten the demise of dictation and its inherent deficiencies.

Although surgeons often struggle with change, I believe the rapid learning curve of these systems and the comprehensive documentation produced will lower the resistance to this change. Adding the benefits of cost savings and immediate billing capability will provide further impetus to the elimination of dictation and transcription.

Learn more about mTuitive OpNote.

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