Dictation Precision: Evaluating Paediatric Oncology Operative Reports as an Impetus for Synoptic Reports.

PURPOSE: The purpose of this study was to audit paediatric surgical oncology dictations to evaluate completeness and ease of data collection and provide a baseline measurement for the implementation of synoptic operative reports (SORs) in a tertiary care setting.

METHODS

An audit tool based on Children's Oncology Group (COG) protocols was created to assess the completeness of surgical and tumour-specific data within operative reports. Audited cases included four paediatric tumours of interest (Germ Cell, Wilms, Neuroblastoma, and Hepatoblastoma) between 2010 and 2023.

RESULTS

Overall, 71 audits were performed, the majority being Wilms Tumour cases (45.1 %), followed by Neuroblastoma (29.6 %), Germ Cell (18.3 %), and Hepatoblastoma (7.0 %). The average percentage of complete data for operative reports was low; the mean completeness of general oncological information for all tumour types was 66.0 %, and tumour-specific details were 42.0 %. Ovarian Germ Cell Tumour had the highest average percentage of complete data (65.9 %), followed by Wilms Tumour (58.7 %), Testicular Germ Cell Tumour (43.0 %), Neuroblastoma (15.0 %), and Hepatoblastoma (9.5 %). The median data collection time was 6.0 min per audit. The median time from the operation to the transcription of the report was 1.0 days (interquartile range (IQR): 1.0-7.0).

CONCLUSION

Narrative operative reports have inadequate completeness, especially concerning tumour-specific factors, which are often essential in accurate diagnosis, and in guiding treatment for children with cancer. SORs could be a solution and aid in the completeness and accessibility of data use.

TYPE OF STUDY: Retrospective review.

LEVEL OF EVIDENCE (I-V): IV.