Completeness of dictated operative reports in breast cancer—the case for synoptic reporting

Journal of Surgical Oncology

Completeness of Dictated Operative Reports in

Breast Cancer—The Case for Synoptic Reporting

LAURA DONAHOE, MD,1* SEAN BENNETT, MSc,1 WALLEY TEMPLE, MD, FRCS(C), FACS,2

ANDREA HILCHIE-PYE, MHSA,1 KELLY DABBS, MD, FRCS(C),3 ETHEL MACINTOSH, MD, FRCS(C),4 AND

GEOFF PORTER, MD, FRCS(C), FACS1

1Queen Elizabeth II Health Sciences Centre/Dalhousie University, Halifax, Nova Scotia, Canada2University of Calgary, Calgary, Alberta, Canada

3University of Alberta, Edmonton, Alberta, Canada4University of Manitoba, Winnipeg, Manitoba, Canada

Background: Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic report-

ing using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was

to determine the current completeness of dictated operative reports for breast cancer surgery.

Methods: An iterative, consensus-based approach to determining elements of a proposed synoptic surgical operative report identified critical

elements. We then evaluated the dictated operative reports of 100 consecutive breast cancer patients for completeness of these elements.

Results: Details regarding presentation and diagnosis were frequently incomplete (84%). Among patients undergoing mastectomy, the poten-

tial for breast conservation was partially described in only 60%. Only 41% had data regarding intra-operative margin assessment during breast

conservation surgery. In axillary lymph node dissections, 92% of patients had complete data about preservation of nerves, yet only 14% of

reports contained complete information regarding sentinel lymph node biopsy. Closure was partially described in 91%.

Conclusions: The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system,

which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.

J. Surg. Oncol. � 2012 Wiley Periodicals, Inc.

KEY WORDS: breast cancer; documentation; surgery

INTRODUCTION

Breast cancer is the second most common cancer affecting Cana-

dian women, resulting in the deaths of approximately 100 women

per week [1]. Although improved treatment has resulted in reduced

breast cancer specific mortality [1], appropriate selection of patients

for the wide variety of treatment strategies and options is critical.

Given that much of the information required to accurately select

patients for appropriate treatment is known upon completion of

breast cancer surgery, and ideally documented in the operative

report, the importance of timely and accurate recording of the opera-

tion is self-evident.

For every surgical procedure that is performed, an operative note

is produced. Traditionally, this has been done as a narrative dictation,

based on the surgeon’s recollection of the details of the procedure.

Although the information provided in operative notes can have

implications on future treatment, few studies have been performed

examining the accuracy of dictated operative notes in breast cancer

surgery. In a study comparing dictated and electronic templates for

operative notes across a variety of gynecologic surgical procedures,

significant delays were found with dictated notes in terms of getting

dictated, verified, and into the patient’s chart [2].

Over the past several years, electronic synoptic reporting for

both cancer pathology and operative reports has emerged as a poten-

tial improvement on existing dictation-based systems [3–6]. Using a

variety of systems, some web-based, completeness and timeliness of

data seems to improve. In Canada, a national initiative sponsored by

the Canadian Partnership Against Cancer has sought to implement

surgical synoptic reporting in several Canadian provinces for breast,

colorectal, ovarian, and oral cancer.

Given our plan to consider widespread adoption of synoptic surgi-

cal reporting for breast cancer in the province of Nova Scotia, we

sought to better understand the content of current dictation-based

operative reports. Thus, the objective of this study is to describe the

frequency of specific elements in the current dictated operative

reports, and identify specific components of the operative note in

most need of improvement.

MATERIALS AND METHODS

In 2008, the Canadian Partnership Against Cancer established

breast cancer as one of the cancer types for which surgical synoptic

reporting via a common operative template was to be tested in sever-

al pilot sites across the country. As part of this national initiative,

an iterative process to establish the elements to be contained in a

breast cancer operative report was initiated, based on previous work

in Alberta, Canada [7]. Within this process, it was acknowledged

that although reports generated from a synoptic reporting template

may contain information depicted elsewhere in the patient’s chart,

the goal of synoptic reporting is to create a useful, complete docu-

ment containing relevant clinical elements, not to minimize the

information included in the operative report. By October 2009, a

The authors have no conflicts of interest.

*Correspondence to: Laura Donahoe, MD, Dalhousie University, Divisionof General Surgery, QEII Health Sciences Centre, 1276 South Park St.,Halifax, NS, Canada B3H 2Y9. Fax: þ902-473-6496.E-mail: [email protected]

Received 17 June 2011; Accepted 12 December 2011

DOI 10.1002/jso.23031

Published online in Wiley Online Library(wileyonlinelibrary.com).

� 2012 Wiley Periodicals, Inc.

pan-Canadian consensus of procedure-specific elements of a breast

cancer operative report was finalized.

Based on this pan-Canadian consensus of important elements

of breast cancer operative reports, a standardized review of the

100 consecutive dictated operative reports performed from July 1,

2009 to September 9, 2009 from the IWK Breast Health Program in

Halifax, Nova Scotia Canada was performed. This program involves

four breast surgeons and performs >80% of breast cancer surgery

within the Capital District Health Authority. A summary of such ele-

ments, reviewed in this study for their presence in the dictated opera-

tive report, can be found in Table I. For the purposes of this study,

we categorized the elements’ presence within the dictated operative

report as either complete, partially complete, or absent. Elements

were considered partially complete when they were mentioned but

did not contain all of the essential information. For example, the

element ‘‘tumor seen on imaging’’ was considered complete when

the type of imaging was noted (e.g., mammogram) and partial

when the operative note referenced imaging of the lesion but the

type of imaging was not recorded. Similarly, for the element of

‘‘pre-operative biopsy,’’ a partial response was one in which it was

discerned a biopsy was performed but the type of biopsy was not

specified, whereas a complete response stated the type of biopsy

done (e.g., core needle biopsy and excisional biopsy). The category

entitled ‘‘choice of surgery for mastectomy patients’’ was calculated

based on whether or not data was available for all of the following

elements: if the patient was a candidate for breast conservation sur-

gery, past personal breast cancer history and size of tumor. If all of

these elements were complete, the ‘‘choice of surgery for mastecto-

my patients’’ was considered complete; otherwise it was considered

partially complete or missing if no elements were described. For sev-

eral elements, a partially complete designation was not possible

(e.g., antibiotic prophylaxis, use of specimen radiography), and such

elements were thus coded as complete or absent.

All data was collected by a single individual (LD) and all statisti-

cal analyses were performed using the statistical software package

SPSS for Windows 9.0 (Chicago, IL). Frequencies were calculated

for each category studied. This study had full approval from the

IWK Research Ethics Board (Project 4799).

RESULTS

Of the 100 charts reviewed, one operative note had not been com-

pleted more than 4 months following the procedure. The character-

istics of the 100-patient study cohort are shown in Table II. The

majority of patients underwent breast conservation surgery (58%),

while 63% of patients underwent concomitant breast and axillary

surgery.

The frequency of reporting of non-technical elements is found in

Table III. Overall, past medical history, use of antibiotic and DVT

prophylaxis, as well as details of metastatic work-up were poorly

described. Variation in the frequency of reporting elements of patient

presentation was found. Although at least one element of the

patient’s presentation was described in 84% of reports, there was

variation in the elements described. For example, reports frequently

described whether or not a pre-operative biopsy was done (56%) and

the clinical node status (83%), but less commonly fully described the

details of the other elements of patient presentation, such as position

in the breast (34%) and whether the lesion was initially identified

TABLE I. Elements Examined From the Dictated Operative Reports

Complete/

absenta

Complete/

partial/

absentb

Non-technical elements

Past medical history X

Candidate for breast conservation surgery X

Details of presentation

Method of detection X

Palpable lesion X

Lesion seen on imaging (including imaging type) X

Pre-op biopsy performed and type X

Position in breast X

Clinical node status X

Size of tumor X

Neo-adjuvant treatment and type X

Metastatic workup—type and results X

Current diagnosis X

Deep vein thrombosis prophylaxis X

Antibiotic prophylaxis X

Choice of surgery (reason for mastectomy) X

Technical elements

Breast conservation

Needle localization use X

Depth of resection X

Intra-operative margin assessment technique

and result

X

Mastectomy

Incision type X

Pectoral muscle resection X

Reconstruction done X

Axillary dissection

Incision X

Margins of dissection X

Nerves identified and preserved X

Sentinel lymph node biopsy

Pre-op lymphoscintigraphy used X

Localization technique(s) used X

Radioactivity of node(s) X

Dye staining of node(s) X

Background counts X

Intra-op pathology assessment done and method X

Intra-operative pathology result X

Conclusion

Blood loss X

Incision closure X

Sponge count completed and correct X

Needle count completed and correct X

Patient status (stable/unstable) X

Unit transferred to X

Dressing applied X

aCoded as ‘‘complete/absent’’ when no details required.bCoded as ‘‘complete/partial/absent’’ when element mentioned but some

essential details potentially missing.

TABLE II. Clinical Demographics of the Study Cohort (n ¼ 100)

Procedure n

Mastectomy 40

Simple 10

Simple þ axillary surgery 30

Breast conservation surgery 58

Lumpectomy alone 25

Lumpectomy þ axillary surgery 33

Sentinel lymph node biopsy alone 1

Axillary lymph node dissection alone 1

Missing 1

Surgeon

A 47

B 16

C 22

D 15

2 Donahoe et al.


clinically or on imaging (50%). Whether the patient was a candidate

for breast conservation surgery was fully described in 48% of all

dictations (i.e., size of tumor, mastectomy due to patient preference).

No patient had all non-technical elements completely described in

their operative report.

Frequencies of reporting of technical operative elements are dis-

played in Table IV. For all patients who underwent breast conserva-

tion surgery (n ¼ 58), 75% had data regarding whether or not needle

localization was used, and 41% had complete information regarding

the use and type of intra-operative margin assessment. The dictated

TABLE III. Frequency of Reporting of Non-Technical Important Elements of the Operative Report (n ¼ 100)

Element n

Fully

described (%)

Partially

described (%)

Not

described (%)

Past medical history 100 0 2 98

Candidate for breast conservation surgery 97b 48 31 21

Details of presentation 100

Method of detectiona 100 50 — 50

Palpablea 100 34 — 66

Seen on imaging 100 36 3 61

Pre-operative biopsy performed and type 100 56 8 36

Position in breast 100 34 3 63

Clinical node status 100 83 0 17

Size of tumora 100 10 — 90

Current diagnosis 100 54 44 2

Antibiotic prophylaxisa 100 7 — 93

Deep vein thrombosis prophylaxisa 100 0 — 100

Metastatic workup 100 2 3 95

Neo-adjuvant treatment and type 100 4 1 94

Metastatic work-up—type and results 100 2 0 98

Choice of surgery for mastectomy patients (i.e., mastectomy vs. breast conservation surgery) 40 0 60 40

‘‘—’’, Not applicable.aPartially described not possible.bBased on all patients who underwent breast surgery, excluding patients who had only axillary surgery.

TABLE IV. Frequency of Reporting of Intra-Operative Technical Elements

Element n

Fully

described (%)

Partially

described (%)

Not

described (%)

Breast conservation 58

Needle localization usea 58 75 — 25

Depth of resection 58 69 2 29

Intra-operative margin assessment technique and result 58 41 17 42

Mastectomy 40

Incision typea 40 38 — 62

Pectoral muscle resectiona 40 77 — 23

Reconstruction donea 40 10 — 90

Axillary dissection 27

Incisiona 27 96 — 4

Margins of dissection 27 74 4 22

Nerves identified and preserved 27 92 4 4

Sentinel lymph node biopsy 44

Pre-operative lymphoscintigraphy used 44 36 12 52

Localization technique(s) useda 44 89 — 11

Radioactivity of node(s)a 44 100 — 0

Dye staining of nodes(s)a 44 95 — 5

Background countsa 44 41 — 59

Intra-operative pathology assessment done and method 44 68 11 21

Intra-operative pathology resulta 44 73 — 27

Conclusion 100

Blood lossa 100 13 — 87

Incision closurea 100 97 — 3

Sponge count completed and correcta 100 24 — 76

Needle count completed and correcta 100 24 — 76

Patient statusa 100 76 — 24

Unit transferred toa 100 77 — 23

Dressing applieda 100 83 — 17

‘‘—’’Not applicable.aPartially described not possible.

Dictated Breast Cancer Operative Reports 3


operative report included the deep resection margin in 77% of mas-

tectomy patients (i.e., whether or not the pectoralis major fascia and/

or muscle was included in the resected specimen), and 92% of

reports stated that the pertinent nerves were identified and preserved

for patients undergoing an axillary lymph node dissection.

Among the 44 patients who underwent sentinel lymph node biopsy,

86% of the operative reports had at least some data regarding details

of the sentinel node procedure. Most reports described the type of

localization technique used (89%; e.g., blue dye, radioisotope injec-

tion), the number of radioactive nodes (100%), the number of nodes

containing blue dye (95%), whether or not intra-operative sentinel

node pathologic examination was performed (68%) and the result

(73%). However, complete sentinel node biopsy information was

only present in 14% of patients.

The reporting of elements occurring at the conclusion of the pro-

cedure is displayed in Table IV. Compared to other technical ele-

ments, many of the conclusion elements were frequently complete in

the dictated operative report, particularly the type of wound closure

performed (97%) and the type of dressing (83%). Overall, 91% of

patients had at least some of these data elements reported.

DISCUSSION

Although many treatment decisions are based upon pathologic

findings, intra-operative elements are also important to optimizing

treatment of breast cancer patients. As such, the operative report

serves as a critical source document of both preoperative and intra-

operative information for other cancer specialists and other members

of the cancer care team. This single-institution consecutive cohort

study demonstrated that the dictated operative report in breast cancer

frequently does not include important information from the surgery

that is often important for subsequent decision-making.

The current standard of documentation for the vast majority of

surgical procedures is the dictated operative report. Often, surgical

residents are given the responsibility of dictating the surgery per-

formed. Despite the importance of this skill for a surgeon, residents

often receive little or no formal training in the intricacies of dictating

a comprehensive and concise operative report [8]. According to

Eichholz et al. [8], only 23% of surveyed surgical residency pro-

grams provide residents with formal teaching of operative dictations.

Residents are expected to include all of the important elements of

the surgery without being told which elements are important. Even

when staff surgeons dictate the report, many important elements are

not included, as has been demonstrated in this study.

Interestingly, this study showed that while vital elements are fre-

quently missing from dictated reports, non-essential data is frequent-

ly included, sometimes with remarkable detail. For example, wound

closure was described in over 90% of this study cohort, often with

the detail of suture type and size, whereas essential details of margin

assessment in lumpectomies were only completely described in 41%

of reports. This reinforces the research that has shown that the im-

portant intra-operative details are often the elements missing from

the non-standardized reports, while non-essential details are fre-

quently included [4]. Perhaps elements that are common to all sur-

geries (such as closure details) are more ingrained in the surgeon’s

personal operative template, and thus are more likely to consistently

appear in the dictated report. It can be hypothesized that stating

the type of suture material used would be much easier to remember

than the often variable details of the patient’s presentation and

prior work-up, both almost never fully described in our study. Intra-

operative details of sentinel lymph node biopsy and lumpectomy

margins were fully described only 14% and 41% of the time, respec-

tively. In contrast, the deep resection margin for mastectomies was

fully included 77% of the time, and 92% of the reports commented

on the preservation of specific nerves during axillary dissection. It is

possible that the recurring anatomic issues of an operative report

(such as nerve preservation) are more frequently described than the

more variable patient-specific details of lumpectomy margins or

details of SLN biopsy.

Attempts to improve the dictated operative reports have been un-

dertaken. Standardized operative reports for laparoscopic cholecys-

tectomy were compared with non-standardized reports; 95–100% of

the standardized reports contained essential intra-operative details,

compared with 14–100% of the non-standardized reports [9]. The

European Organization for Research and Treatment of Cancer

(EORTC) implemented a standardized collection form for breast can-

cer surgery and found great variability in the quality of surgery being

performed [10]. As surgical techniques have been standardized to

ensure high quality care of patients, operative reports must follow.

In an effort to improve the quality of cancer care, Cancer Surgery

Alberta in Alberta, Canada, created a web-based synoptic operative

report (WebSMR); through this, templates have been created for a

variety of cancer operations, and it has replaced the standard opera-

tive dictation in select centers across Canada [3,4]. It emphasizes

real-time dictation and completeness and accuracy of data included.

Not only does it include vital aspects of the operation, it also

requires surgeons to enter data about the history of the patient and

circumstances surrounding their surgery. Chambers et al. [4] studied

the use of the WebSMR for thyroid cancer and found that important

details were included <30% of the time in the dictated report, while

non-essential data was included more than 80% of the time. For rec-

tal cancer, Edhemovic et al. [3] found that WebSMR was complete

while only taking an average of 6 min to complete; essential intra-

operative details were included in only 33.5–47.5% of dictated

reports. Similarly, an electronic synoptic operative report (E-SOR)

has been created at Memorial Sloan-Kettering Cancer Centre

(MSKCC) for pancreatic resections. With the same principles of

completeness and timeliness in mind, the MSKCC group calculated

inter-observer agreement and completeness scores for the E-SOR,

completed by both an attending surgeon and surgical fellow.

The results showed moderate to very good reliability for individual

E-SOR items studied, and a significantly higher completeness score

for the E-SOR compared to the dictated operative report [6].

Synoptic reporting is becoming increasingly common in other

specialties, particularly pathology. In Ontario, an initiative was un-

dertaken to improve the quality of pathology reports for select types

of cancer, breast included. Srigley et al. [11] outlined timeliness,

accuracy, completeness, and usability as the four essential elements

required of pathologic reporting; the same standards can be used for

surgical reports. As treatment of cancer is multi-disciplinary involv-

ing surgeons, pathologists, radiologists, and oncologists, the details

of operative reports must be accurate as well as user-friendly so

that all essential details can be abstracted by the other specialties

involved in the care of the patient. As well, the reports must be

produced in a timely manner; often elements relevant to the patho-

logic analysis of the specimen may not be available to the patho-

logist except in the operative report, emphasizing the necessity of

producing an accurate, detailed report in a timely fashion [11].

Although strengthened by its consecutive cohort design, this study

did reflect the experience of only four breast surgeons at an academ-

ic tertiary care center, potentially limiting its generalizability to other

centers or surgeons. However, given that the majority of breast sur-

gery in Canada is performed in the community hospital setting [12],

it is possible that the true presence of specific elements in these dic-

tated reports is even lower than that found in this study. This study

describes the current standard dictated report in breast cancer sur-

gery, thus no direct observations about improvement with electronic

synoptic reporting can be made. However, the institution of synoptic

reporting will immediately increase the reporting of specific pre-

determined elements in the operative note to 100% as the fields for

4 Donahoe et al.


these elements can be made mandatory; a report cannot be generated

unless they are completed. Although the presence and completeness

of specific elements of the operative report have been described in

this study, we did not assess accuracy; this would require correlation

of stated elements with other data sources and for surgical elements

this would require real-time observation. Finally, an iterative and

expert consensus-based approach to the designation of elements of a

breast cancer operative report was used. Wide variation exists in the

level of evidence in breast cancer surgery making a pure evidence-

based approach to inclusion/non-inclusion of elements impractical.

For example, high-level evidence exists regarding the choice of

mastectomy versus breast conservation surgery whereas much lower

level evidence exists regarding the depth of resection in breast

conservation.

The content elements identified in the pan-Canadian consensus-

based approach may be viewed as too extensive in that some ele-

ments may be found elsewhere in the medical record. However, the

pan-Canadian approach sought to identify elements for an ideal, not

minimal, document. A consequence of creating a complete docu-

ment, which can be used as a reference for both the surgeon and

other physicians in making future treatment plans, is the fact that the

final report may be longer than a suboptimal narrative report. De-

signing synoptic reporting tools, by its very nature, requires consid-

eration of the tension between too much information where surgeons

may object to the time investment required, and too little information

where important data is not collected [13]. Finally, even if one only

considers essential elements of a breast cancer operative report, this

study still shows such elements to be suboptimally reported. For

example, full or partial description of tumor position in breast

was only 37%, size of tumor was only 10%, and intra-operative

pathology assessment of sentinel lymph nodes was only 73%.

There are potential sources of resistance to the introduction of

new system(s) to improve operative reports in cancer surgery. The

current Canadian Partnership Against Cancer initiative examines,

in a multi-province pilot fashion, the feasibility of more widespread

implementation of surgical synoptic reporting [14]. This initiative

and its findings will be critical to the potential widespread adoption

of electronic synoptic reporting in cancer. Alternative systems, such

as implementing a ‘‘reminder card’’ for surgeons to improve the con-

tent of narrative reports, has not been evaluated in cancer surgery.

Although it may be difficult to establish a clear causal relationship

between improved operative reports and improved patient outcomes,

it is hoped that ensuring inclusion of important operative details will

contribute to providing the highest quality of patient care possible.

CONCLUSION

The dictated operative report for breast cancer surgery does not

adequately capture important data and improvement is necessary. A

synoptic reporting system, where such elements are required, would

appear to be a potentially beneficial tool in breast cancer surgery.

REFERENCES

1. Canadian Cancer Society: 2010. Breast Cancer Statistics.Available http://www.cancer.ca/Canada-wide/About%20cancer/Cancer%20statistics/Stats%20at%20a%20glance/Breast%20cancer.aspx?sc_lang¼en [accessed February 5, 2011].

2. Laflamme MR, Dexter PR, Graham MF, et al.: Efficiency, com-prehensiveness and cost-effectiveness when comparing dictationand electronic templates for operative reports. AMIA SympProc 2005;2005:425–429.

3. Edhemovic I, Temple WJ, de Gara CJ, et al.: The computersynoptic operative report—A leap forward in the science of sur-gery. Ann Surg Oncol 2004;11:941–947.

4. Chambers AJ, Pasieka JL, Temple WJ: Improvement in the ac-curacy of reporting key prognostic and anatomic findings duringthyroidectomy by using a novel Web-based synoptic operativereporting system. Surgery 2009;146:1090–1098.

5. Wilkinson NW, Shahryarinejad A, Winston JS, et al.: Concor-dance with breast cancer pathology reporting guidelines. J AmColl Surg 2003;196:38–43.

6. Park J, Pillarisetty VG, Brennan MF, et al.: Electronic synopticoperative reporting: Assessing the reliability and completenessof synoptic reports for pancreatic resection. J Am Coll Surg2010;211:308–315.

7. Temple WJ, Francis WP, Tamano E, et al.: Synoptic surgicalreporting for breast cancer surgery: An innovation in knowledgetranslation. Am J Surg 2010;199:770–775.

8. Eichholz AC, Van Voorhis BJ, Sorosky JI, et al.: Operative notedictation: Should it be taught routinely in residency programs?Obstet Gynecol 2004;103:342–346.

9. Harvey A, Zhang H, Nixon J, et al.: Comparison of data extrac-tion from standardized versus traditional narrative operativereports for database-related research and quality control. Sur-gery 2007;141:708–714.

10. Christiaens MR, van der Schueren E, Vantongelen K: Moredetailed documentation of operative procedures in breast con-serving treatment: What good will it do us? Eur J Surg Oncol1996;22:326–330.

11. Srigley JR, McGowan T, MacLean A, et al.: Standardized syn-optic cancer pathology reporting: A population-based approach.J Surg Oncol 2009;99:517–524.

12. Porter GA, MacMulkin H: Practice patterns in breast cancer sur-gery: A Canadian perspective. World J Surg 2004;28:80–86.

13. Park J, Pillarisetty VG, Brennan MF, et al.: Electronic synopticoperative reporting: Assessing the reliability and completenessof synoptic reports for pancreatic resection. J Am Coll Surg2011;211:308–315.

14. Cancer Surgery Alberta: 2011. Canadian Partnership AgainstCancer. Available http://www.cancersurgeryalberta.ca/canadian-partnership-against-cancer-cpac [accessed February 5, 2011].

Dictated Breast Cancer Operative Reports 5


Documents

Completeness of dictated operative reports in breast cancer—the case for synoptic reporting