The Laryngoscope · 2026
EHR-Integrated Synoptic Operative Reporting for Head and Neck Oncologic Surgery.
СтатьяНазвание и аннотация: Перевод в очереди
Обработка статьи · этапы, ошибки и управление
Загрузка состояния…
Ошибки и ограничения
История · было → стало
Состояние обновляется каждые 5 секунд, пока блок открыт. Процент показывается только там, где известен объём работы. Пауза останавливает продолжение этапа; текущий запрос к источнику может завершиться.
Lango Miriam N, Sinnathamby Avery, Nader Marc-Elie, Gidley Paul W, Choi Karen Y, Zafereo Mark, Barbon Carly E A, Pytynia Kristen B, Maniakas Anastasios, Hessel Amy, Goepfert Ryan P, Ahmad Faisal I, Anderson Jennifer L, Kapur Sahil K, Taylor Jolyn S
Аннотация
OBJECTIVE: To describe the development and implementation of electronic health record (EHR)-integrated synoptic operative templates for head and neck oncologic surgery and to evaluate documentation adherence and performance.
METHODS: Single-institution retrospective quality improvement study of extirpative oncologic resections (mucosal, cutaneous, thyroid, salivary gland, and skull base) performed at a tertiary academic cancer center from January 2025 through April 2026. Tumor-specific adaptive synoptic templates were developed through literature review, professional society guidance, and subspecialty consensus and integrated into the EHR. Adherence was defined as synoptic template use for eligible cases; performance was defined as the proportion of cases with complete and internally consistent synoptic data, with an acceptable rate set at 90% or higher. The first 253 consecutive cases with synoptic documentation underwent detailed performance review.
RESULTS: Departmental adherence increased from 49% to 69%-78% over the final 6 months and varied among surgeons (range, 7%-100%). Surgeons who personally completed operative reports adhered more often than those delegating to trainees (85% vs. 56%; p < 0.001), as did high-volume surgeons (85% vs. 56%; p < 0.001). Among 253 reviewed cases, 239 (94.5%) met the completeness and consistency target. Missing data exceeded inaccuracies (12 vs. two cases). Performance failures were more frequent with the thyroid template than with all other templates combined (10.8% vs. 1.8%; p < 0.001).
CONCLUSION: EHR-integrated synoptic operative templates for head and neck oncologic surgery demonstrate acceptable documentation performance but variable uptake. The underlying structured data framework may support multicenter standardization, registry-based outcomes research, and AI-enabled surgical documentation.
LEVEL OF EVIDENCE: Not applicable.
METHODS: Single-institution retrospective quality improvement study of extirpative oncologic resections (mucosal, cutaneous, thyroid, salivary gland, and skull base) performed at a tertiary academic cancer center from January 2025 through April 2026. Tumor-specific adaptive synoptic templates were developed through literature review, professional society guidance, and subspecialty consensus and integrated into the EHR. Adherence was defined as synoptic template use for eligible cases; performance was defined as the proportion of cases with complete and internally consistent synoptic data, with an acceptable rate set at 90% or higher. The first 253 consecutive cases with synoptic documentation underwent detailed performance review.
RESULTS: Departmental adherence increased from 49% to 69%-78% over the final 6 months and varied among surgeons (range, 7%-100%). Surgeons who personally completed operative reports adhered more often than those delegating to trainees (85% vs. 56%; p < 0.001), as did high-volume surgeons (85% vs. 56%; p < 0.001). Among 253 reviewed cases, 239 (94.5%) met the completeness and consistency target. Missing data exceeded inaccuracies (12 vs. two cases). Performance failures were more frequent with the thyroid template than with all other templates combined (10.8% vs. 1.8%; p < 0.001).
CONCLUSION: EHR-integrated synoptic operative templates for head and neck oncologic surgery demonstrate acceptable documentation performance but variable uptake. The underlying structured data framework may support multicenter standardization, registry-based outcomes research, and AI-enabled surgical documentation.
LEVEL OF EVIDENCE: Not applicable.