Assessing the Impact of a Standardized Operation Note to Improve the Quality for Laparoscopic Cholecystectomy

Abstract

Operation notes are essential for effectively communicating patient care, resident education, and information to surgeons and serve as a resource tool for research and outcome improvement. Additionally, they offer a mechanism for healthcare reimbursement and an enhancement in the care quality. There is an increasing recognition of the importance of synoptic operative notes that are procedure-specific and templated. The inclusion of archived (and retrievable) video recordings and intraoperative photographs has the potential to improve the reporting of a wide range of medical procedures, not just surgical procedures. Physician and patient concerns regarding privacy, data protection, and potential medico-legal exposure must be addressed as part of change management in surgery. Globally, laparoscopic cholecystectomy (LC) is one of the most frequently performed operations, with more than 1.1 million procedures performed annually in the United States alone. A transparent description of operative findings and procedures is recommended in order to understand the patient's path to recovery and potential adverse outcomes, which may occur in up to 20% of patients.