Health informatics journal
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Health Informatics J · Dec 2016
Synoptic operative reports for spinal cord injury patients as a tool for data quality.
The advent of synoptic operative reports has revolutionized how clinical data are captured at the time of care. In this article, an electronic synoptic operative report for spinal cord injury was implemented using interoperable standards, HL7 and Systematized Nomenclature of Medicine-Clinical Terms. Subjects (N = 10) recruited for a pilot study completed recruitment and feedback questionnaires, and produced both an electronic synoptic operative report for spinal cord injury report and a dictated narrative operative report for an actual patient case. ⋯ Data quality improved. Electronic synoptic operative report for spinal cord injury reports were more complete (95.26%) than dictated (80%) for all subjects. An accuracy assessment, which considered usability for secondary data use, was conducted and the electronic synoptic operative report for spinal cord injury was demonstrated to improve accuracy.