Abstract
Abstract
Background
Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future.
Methods
A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one “ideal” laparoscopic operative report template following international input from the World Society of Emergency Surgery board.
Results
A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic.
Conclusion
This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals’ medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.
Publisher
Springer Science and Business Media LLC
Subject
Emergency Medicine,Surgery
Reference54 articles.
1. Parwaiz H, Perera R, Creamer J, Macdonald H, Hunter I. Improving documentation in surgical operation notes. Br J Hosp Med (Lond Engl 2005). 2017;78(2):104–7.
2. Doyen EL. The cinematograph and the teaching of surgery. Brit Gynaec J. 1899;155:579–86.
3. Baigrie RJ. An audit of the quality of operation notes in two district general hospitals. Are we following royal college guidelines? Ann R Coll Surg Engl. 1994;76(1 Suppl):8–10.
4. Stanley-Brown EG. How to dictate operative notes. Resid Staff Physician. 1983;29(2):109–10.
5. Ballester. New operative reporting standards: where we stand now and opportunities for innovation. Ann Surg Oncol. 2021. https://doi.org/10.1245/s10434-021-10766-9.
Cited by
5 articles.
订阅此论文施引文献
订阅此论文施引文献，注册后可以免费订阅5篇论文的施引文献，订阅后可以查看论文全部施引文献