Structured panendoscopy reports improve report completeness and documentation time

Abstract

Even today, surgical reports are usually dictated in a free text form (FTR), leading to a wide range in report-quality. This study investigated the use of a fully structured panendoscopy report (SR) compared to FTRs. 64 panendoscopies were performed by three experienced head and neck surgeons. The surgical reports were created as both FTRs and SRs, which were examined regarding time to completion and content using a multilevel regression analysis. User satisfaction was evaluated using a questionnaire. There was no significant difference in time to complete the SRs compared to FTRs. The completeness ratings of SRs were significantly higher than for FTRs (81% vs. 66%, p < 0.001), leading to increased report quality. Overall user satisfaction was higher for SRs than for conventional FTRs (VAS 8.1 vs. 3.5, p < 0.001). The SRs proved to be fast to complete and more comprehensive with a higher completeness of content. Participating surgeons indicated that they preferred SRs over FTRs because of their advantages in terms of structure, guidance for inexperienced residents and non-native speakers. The data stratification also enables secondary data use to further develop deep learning algorithms in patient care and research.

Keywords: Digitalization; Free text reports; Otorhinolaryngology; Panendoscopy; Structured reporting.

Fig. 1

This is a screenshot of the web-based tool developed by Smart Reporting GmbH, Munich, Germany (https://www.smart-reporting.com). The panendoscopy report template shown was created by a group of experienced head and neck surgeons prior to the study. On the left, a side bar provides a general structure; a standard panendoscopy report can be generated by clicking on ‘normal findings’ (‘Normalbefund’). In the middle, a clickable decision tree guides the surgeon through the entire operation. The automatically generated full text is shown on the right.

Fig. 2

The structured template used in this study includes sketch elements that allow the surgeon to draw in pathological findings. This graphical presentation of information can be a valuable addition to the written report.

Fig. 3

This graph shows the time taken to complete the documentation separately for the three different surgeons using the structured report form (SR; orange) and free text (FTR; blue). A data table shows the exact time in seconds for SR and FTR.

Fig. 4

The completeness of documentation is given in this graph for structured reports (SR; orange) and free text reports (FTR; blue) separately, grouped as follows: insufficient: 0–20%, poor: 20–40%, moderate: 40–60%, high: 60–80%, very high: 80–100% completeness. No report achieved less than 40% completeness. The data table below shows the exact percentages of panendoscopy reports in each category.

Fig. 5

User satisfaction for the two documentation methods structured reporting (orange) and free text reporting (blue) on a VAS (scores 0–10) are given as the mean. The items surveyed were the expected benefit for inexperienced physicians to perform surgery and to improve documentation, time efficiency, report quality, applicability and practicability. In all categories, SRs were superior to FTRs with overall satisfaction being significantly higher regarding SRs (*p < 0.001).