EHR-Integrated Synoptic Operative Reporting for Head and Neck Oncologic Surgery.

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.