Standardizing OR notes facilitates communication across specialties

When it comes to quality initiatives, even the smallest standardization can result in an improvement in patient care. Standardizing operating room notes, for example, is one of the ways surgeons can increase ease of collaboration and leave less room for errors in reporting.

“My service often collaborates with other departments, like, for instance, pathology,” said Ibrahim Nassour, M.D., MSCS, assistant professor in the division of surgical oncology. “And they already established synoptic pathology reports. We, on the other hand, sought to establish synoptic reporting for operative notes.”

Now, Nassour said, each surgeon fills out a synoptic report where they identify the diagnosis, describe the margin, whether or not the margin has been disturbed, and other relevant details. Keeping a consistent format makes it much harder to forget certain details, and acts like a visual heuristic for other surgeons and services reviewing the notes after the procedure.

Specifically, Nassour and his team began synoptic reporting for gastrointestinal cancers with an emphasis on pancreatic cancer. They also began synoptic reporting for HIPEC procedures, which is a targeted surgical technique used to address disseminated cancer in the peritoneal cavity.

“Once we established synoptic reporting for the operative note, we also began collaborating with our radiology colleagues, having them also begin to engage in a specific synoptic reporting that would complement the synoptic reporting we use when it comes to GI cancer,” Nassour said.

A key takeaway is that the standardization of OR notes and reporting increases the chance for physicians to engage in best practices, Nassour pointed out. When all the notes are synoptic, and specific criteria are identified, physicians can put together a comprehensive treatment plan faster. In a way, it acts as a blueprint to eliminate mistakes and increase chances of operative and postoperative success.

“It has become especially effective in helping us follow our postoperative outcomes, as well as the factors contributing to those outcomes,” Nassour said. “In turn, this helps us identify ways to improve our procedures moving forward, and know if there are any issues in quality early on.”

Nassour credits the effort’s success to the collaborative, hard work of the multidisciplinary teams involved.

“The goal of every team I have had the privilege of working with is to provide good patient care,” Nassour said. “And I think we collectively understand that in order to provide good patient care consistently, being able to follow our quality outcomes and note what contributes to them is very important.”