Probably the earliest recorded “operative report” was that of Paul of Aegina in the 7th century a.d. describing his method of performing a tonsillectomy:
“Wherefore, having seated the patient in the sunlight, and directed him to open his mouth, one assistant holds his head and another presses down the tongue with a tongue depressor. We take a hook and perforate the tonsil with it and drag it outwards as much as we can without dragging the capsule out along with it, and then we cut it off by the root with the tonsillotome suited to that hand, for there are two such instruments having opposite curvatures. After the excision of one we may operate on the other in the same way.”
From that description, the “art” of archiving operative events evolved significantly over many centuries. Only six years after its founding, the American College of Surgeons proposed a template for the written description of an operative event and published it in the January 1919 ACS Bulletin. Some years later, the mostly written format transformed into recorded narrative renderings as dictating equipment and transcription services in hospitals evolved. We all grew up using some form of narrative description, although there was no standardized approach to capture the important elements of the operation. I am also sure that most of us received little in the way of training and direction as to the correct formatting of these notes. It was assumed that most surgical residents who were allowed to dictate after their operative experiences were born with some innate concept of how an operation should be chronicled!
Over the last 10 to 15 years, the notion of the “synoptic” operative template or checklist approach to operative recordings has gained traction, just as this form of reporting endoscopic and physical examinations has gained acceptance. The word synopsis is derived from two ancient Greek words: s=n (“with or whole”) and Ópsis (“view”). If done correctly, the synoptic approach gives an abbreviated, but overall view of an activity, whether it be an endoscopic event, physical exam or operative report. Multiple articles in the peer-reviewed literature have supported the notion that these templative approaches may actually capture the important elements of an operation better than the traditional narrative formats and, perhaps more importantly, allow for more complete billing! Recommendations for including use of operative templates especially in resident training also have sent a clear message to all residency training directors.
I am particularly delighted that the new 2020 Standards of the ACS Commission on Cancer introduced the concept of reporting essential elements of a cancer operation using a synoptic template. These standards will be highlighted outside of the traditional narrative or operative templates used. By means of this approach, important components of oncologic procedures will be mandated, and recognition of these standards will be made easier at future accreditation site visits. There are two important barriers to using information: 1) a significant amount of information is locked in text format, making it difficult to pull from the records; and 2) the textual information in the record is variable in content, accuracy and quality. These two barriers limit the usefulness of information, which becomes particularly evident when attempting to measure and track quality. An ideal future state involves surgeons having an efficient mechanism to document relevant information that allows for automatic extraction for use in front-line clinical care tools and for quality and research purposes.
My main concern, however, as one trained to report using a narrative approach, is that we may find it more difficult to personalize our operative descriptions in the future as we migrate to complete templative reporting. Will the templates allow for archiving all important elements of an operation? Will a template permit describing any unforeseen issues that arise? Will the template give opportunity to describe arcane anatomic variants? We must always realize that not only is the operative record the best source of cataloging and subsequently reviewing an operative event; it is also a formidable medicolegal document. Will a templative approach satisfy that role? Stay tuned!
Dr. Greene is the senior medical advisor for General Surgery News.
This article is from the December 2021 print issue.
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