Electronic synoptic operative reporting for thyroid surgery using an electronic data management system: potential for prospective multicenter data collection.

Overview

BACKGROUND: Electronic synoptic operative reports ensure systematic documentation of all critical components and findings during complex surgical procedures. Thyroid surgery lends itself to synoptic reporting, because there are a predefined number of essential intraoperative events and findings that every endocrine surgeon invariably records. METHODS: An electronic web-based form (e-form) was designed and implemented to record operative data in a synoptic structure for thyroid surgery. The e-form was implemented as a pilot study from January 2008 to October 2009 for use by three attending surgeons. RESULTS: During this period, 514 e-forms were completed with 100% compliance, which recorded data from 384 total thyroidectomies and 130 thyroid lobectomies. All users found the e-form to be easy to use, comprehensive, and took less than 5 min to complete. CONCLUSIONS: The main advantages of a web-based e-form for synoptic recording of thyroid surgery are that it is user-friendly and easy to complete, yet comprehensive. Because it is based on a system available across institutions, it can be used as a minimum dataset and could be considered a national and international standard for wider use, especially if endorsed by the American or International Association for Endocrine Surgeons.