Over the recorded history of surgery, the operative note’s function has changed from a narrative description, which persists today, to a document that includes additional information that affects billing and coding, and carries medicolegal importance as well.

The words surgeons use to describe what we do must be translated into a recognized service or CPT code otherwise known as the “op note.” In fact, when doing research for this article, “Auf Henweis” came up when searching the term “op note” in an online translator. After checking with other German-speaking people, perhaps “Operationsbericht,” or “Chirurgisch Notiz” would be more appropriate or accurate translations. The German title was used to represent the work our coding professionals do when trying to assign the correct meanings in translating our narrative notes for the procedures we perform.

As Dr. Frederick Greene pointed out in his December 2021 editorial [“Templative Operative Reporting: A Caveat,” page 3], synoptic reporting is being revisited to provide the “whole view.” Increasingly, the reality that surgeons’ narrative reports miss elements that affect financial and data extraction functions would seem to suggest we should evaluate the process of procedural documentation.

Synoptic reporting has been introduced successfully in other medical disciplines, such as pathology and radiology, to cover elements that could be, and sometimes are, omitted by the recording physician. The Committee on Cancer has adopted the synoptic process for selected malignancies to facilitate data analysis and comparison. Increasingly, surgical subspecialties use registries in pursuit of the capability for comparative analysis. Consider the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), the Metabolic and Bariatric NSQIP, the Society of Thoracic Surgeons, among many others. In the January 2014 issue of the Journal of the American College of Surgeons common (218[1]:113-118), operative report training—including synoptic style—was evaluated by 441 program directors, who concluded that the synoptic style was not common. Additionally, although teaching operative documentation was considered valuable, it is not widely done.

If we separate the functions of the procedural documentation into parts, we could consider several, including but not limited to:

• narrative
• medicolegal
• billing and coding
• data retrieval elements

The narrative approach is clearly the long-standing technique, dating to the origins of surgery several thousand years ago. This is perhaps because surgeons regarded their work as an art form serving the population. Recording the techniques would be used for teaching purposes and expression of pride in accomplishment. When we look today at narrative procedural descriptions, many different personalities emerge. Although the ranks of documentation minimalists are many, elaborate multiple-page descriptions also exist for similar operations that document elements of operative events in painstaking detail. The medicolegal protection or exposure can be debated, but there is no question the procedural note can be viewed retrospectively, and differing conclusions can be drawn about the conduct and execution of the operation. While some surgeons feel more detail is always better, the documentation minimalist would obviously not share this opinion.

The billing and coding function of the operative note has been increasing in importance ever since the American Medical Association released the Current Procedural Terminology (CPT) coding book in 1966. Surgical coding involves a five-digit code between 10000 and 69990, broken down into the system addressed. Unfortunately, all our narrative descriptions must be translated into one of the existing codes for accurate usage. Some surgeons are quite facile at selecting the appropriate codes that match the narratives produced, whereas others leave the selection to the health information management professionals who read and assign codes based on content. Differences in work relative value units (wRVU) in families of codes can be significant based on one word in the narrative. (The wRVU is the reimbursement integer that is consistent regardless of geography.) Many wRVU changes are based on the size of a lesion down to the millimeter, depending on specific location, and others require specific disclosure of the level or depth of surgical dissection, changing the meaning and wRVU. We are charged with producing the operative note immediately after an operation; occasionally this involves a brief note followed later by the complete narrative, and this is shared with other nurses and doctors involved in the case. If changed later, the operative note can be incongruous with that recorded by the others involved.

Benchmarks are used to compare surgeons in several hospitals. Perceived quality can be affected by omitting coding details not known by the surgeon or included in the operative note. A diagnosis of appendicitis versus acute appendicitis versus appendicitis with abscess carries a different expected length of stay and severity of illness assignment, which affects hospital reimbursements. The more complicated versions cannot be inferred simply because the patient’s stay is longer or has a persistent fever.

The data collection function, which should help us efficiently manage our expenses and the diseases we treat, is disappointingly lacking. A surgical colleague and friend, Dr. Bruce Ramshaw, has dedicated his surgical career to building tools to help data aggregation. He quipped to me that professional baseball, among other businesses, does a much better job than surgery with statistical analysis based on data entry. More than 25 years ago, elaborate statistical analysis was used in baseball to discern the minutiae necessary to compare performance and efficiency. In medicine, we have so many discordant systems that comparisons are almost impossible to make due to the lack of consistent entry (“garbage in, garbage out”).

Clearly, our survival as surgeons depends in part on improvements and efficiencies that can be elucidated by appropriate data entry and analysis. Many surgeons have a poor understanding of the reimbursements offered by third-party payors to cover the expensive tools we use. Data analysis can help. Data analysis can uncover practices that can be improved for patient benefits. Data analysis can be used to improve facility efficiency and financial stability. Data analysis can help patients trust where care delivery is likely to be superior. Obviously, this is a critical addition that can be bolstered by this function of procedural documentation.

As we work with so many electronic health record tools, clearly tools exist to help. My bias is to continue to develop hybrid tools that allow narrative documentation but also offer a synoptic format to serve coding, billing and data requirements. Surgeons are typically resistant to change, but when change creates benefits that are financially rewarding and helpful, they should be considered.

Dr. Newman is a surgeon from Gadsden, Ala. He is the chief medical information officer at Nuance Healthcare and the founder of Nuance SCAPD.