EHR-Integrated Synoptic Operative Reporting: Enhancing Documentation in Head and Neck Oncologic Surgery

Highlight

– Development and EHR integration of tumor-specific synoptic operative templates for head and neck cancer surgery.
– Documentation adherence increased from 49% to nearly 78% over study period, with variability among surgeons.
– Completeness and internal consistency of synoptic reports achieved a high target rate of 94.5%.
– Thyroid surgery templates showed a higher rate of documentation failures compared to other tumor sites.

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