Alvaro Mendez, MD, Caren Nituda, BSN, RN, CEN, CPON, Raymond Yap, MD, BmedSci, MsurgEd, FRACS, Arman Erkan, MD, Justin Kelly, MD, FRCS, Bruce Orkin, MD, FACS, FASCRS, John Rt Monson, MD, FRCS, FACS, FASCRS. AdventHealth
Introduction: The National Accreditation Program for Rectal Cancer (NAPRC) has released guidelines for operative reports, that contains twenty mandatory elements (ASA score, case status, name of operation, modality, tumor location, distance from anal verge, mobilization of splenic flexure, level of ligation of IMV, level of ligation of IMA, distal margin, type of reconstruction, anastomotic testing method, creation of stoma, en-bloc resection, metastectomy, completeness of tumor resection, intraoperative complications, blood transfusion, TME photographed and short narrative). Although previous studies have highlighted deficiencies in narrative operative reports, there has been no comparison to the elements requested in the NAPRC guidelines. The aim of this study is to assess and compare current narrative operative reports to the new national standard.
Methods and Procedures: Data from consecutive rectal cancer operative reports from two tertiary institutions in 2016-17 was extracted and analyzed. Each note was independently graded on the 20 elements required by the NAPRC.
Results: A total of 100 operation notes were analyzed. Overall, adherence to the NAPRC standards was only 56.1%. Four elements (case status, operation, modality and the short narrative) were present in 100% of reports. A further four elements (IMA and IMV level ligation, mobilization of splenic flexure and stoma) scored above 60%. Four seemingly important elements (distal margin, completeness of the resection, distance from the anal verge range and tumor location) were only documented in 10-40% of cases. Not a single report included either ASA or documentation that the TME specimen had been properly photographed.
Conclusion: The evaluation of current operative reports shows that compliance with new NAPRC guidelines for operative reporting was low. A significant improvement in current documentation practice is required to achieve NAPRC accreditation standard. Synoptic reporting may provide a solution to this challenge.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94561
Program Number: P323
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster