Cookies on this website

We use cookies to ensure that we give you the best experience on our website. If you click 'Accept all cookies' we'll assume that you are happy to receive all cookies and you won't see this message again. If you click 'Reject all non-essential cookies' only necessary cookies providing core functionality such as security, network management, and accessibility will be enabled. Click 'Find out more' for information on how to change your cookie settings.

OBJECTIVE: Extracting complete and accurate records of surgical procedures from case-notes is time consuming and laborious. We compared the completeness and time taken to extract data on surgical procedures from case-notes and from pathology reports. STUDY DESIGN AND SETTING: Information on surgical procedures was extracted from pathology reports and hospital case-notes for 111 women with breast cancer in three centers. The time taken to perform this task was recorded. Surgical procedures were classified into diagnostic and therapeutic procedures, and analysis was performed to determine the completeness and accuracy of the documentation of the procedures. RESULTS: The average time taken to extract relevant information from the pathology reports (3.0 minutes) was one-fifth that for the case-notes (14.4 minutes). The case-notes documented slightly fewer procedures than the pathology records: 94 vs. 108 diagnostic and 108 vs. 110 therapeutic procedures, respectively. Of the 219 therapeutic and diagnostic surgical procedures recorded by both data sources, for 216 procedures there was exact agreement as to the specific type of procedure performed. CONCLUSIONS: Extraction of information on surgical procedures is faster from pathology records than from case-notes. The level of agreement for the specific type of procedure performed is excellent and, if anything, the pathology records are more complete than the case-notes.

Original publication

DOI

10.1016/j.jclinepi.2007.05.016

Type

Journal article

Journal

J Clin Epidemiol

Publication Date

04/2008

Volume

61

Pages

402 - 406

Keywords

Breast Neoplasms, Cohort Studies, Databases, Factual, Documentation, Female, Humans, Information Storage and Retrieval, Lymph Nodes, Mastectomy, Mastectomy, Segmental, Medical Records Systems, Computerized, Middle Aged, Pathology, Surgical, United Kingdom