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The menisci of the knee are accurately evaluated by MRI. Knowledge of normal anatomy, imaging parameters, imaging appearance of the normal and torn meniscus, and common anatomic variants and pitfalls are essential in obtaining the correct imaging diagnosis. There are multiple imaging signs of meniscal tear, including linear signal intensity extending to an articular surface on at least 2 images, altered meniscal shape, displaced meniscal flap, ghost meniscus, meniscal extrusion, and parameniscal cyst. After surgery, granulation tissue may mimic tear. Diagnosis is improved by comparison to preoperative images, operative note, and intra-articular contrast administration.

Background Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption. Methods In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches. Results From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value

Wilder Penfield (1891–1976) is widely regarded as a dominant figure in 20th century neurobiology for his singular contributions to the structure-function relationship of the brain, his discovery of the language function of the supplementary motor area, the discovery (with Herbert Jasper and Brenda Milner) of the anatomy of recall, and his pioneering work in the surgical treatment of focal epilepsy. But another of his significant discoveries has escaped notice: the recognition that focal microgyria can generate epileptic seizures, and that these can be treated surgically. Penfield discussed the case of the patient through which this discovery was made during his Shattuck Lecture to the Massachusetts Medical Society in 1939. As Penfield gave only a fragmentary account of this case, the patient's chart was retrieved from the Montreal Neurological Institute archives, and his operative note and brain map, intraoperative photographs, and the histopathological and cytological examinations of the resected specimen were reviewed. Based on these primary sources, this paper provides a complete, detailed account of the first case in which microgyria was recognized as a cause of focal epilepsy, which was successfully treated surgically.

Objective: To determine the frequency of adherence of laparoscopic appendectomy operative notes with the Royal College of Surgeons (RCS) guidelines at the tertiary care centre. Study Design: A clinical audit report. PLACE AND DURATION OF STUDY The Aga Khan University Hospital, Karachi between January and June 2018. METHODOLOGY Operative notes of laparoscopic appendectomy, written by residents of general surgery from trainee levels R1 to R5 during the study period, were included in the study. Each component from RCS guidelines, was assessed. The response to every question in proforma was marked either as Y=Yes or N=No. Overall score of more than 70% was chosen arbitrarily as a qualifying standard for an adequate operative note. Data were analysed by using SPSS (version 21). A p-value of

Background: Both from a medical and legal point of view, the quality of operative notes are important. in this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. Methods: A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in -clinic training session and guidelines were dis- cussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re -audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. the results of each audit were compared. Results: in the first audit, it was found that fourteen parameters were written with more than 90% accuracy. the first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), pa- tient position (1.3%), and amount of bleeding (0%). in the second audit there was an incom- plete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compli- ance in all parameters. Conclusion: This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. the use of proforma pro- vides much better results. (C) 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B. V. This is an open access article under the CC BY-NC- ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

BACKGROUND Decompressive hemicraniectomy (DHC) is well established as an effective life-saving intervention. Although literature documents a correlation between mortality and hemicraniectomy flap size, no literature exists demonstrating whether a larger flap may be achieved with 3-pin fixation devices versus nonfixed positioning (e.g., occipital headrest, gel donut). Therefore, positioning for DHC remains the preference of the institution and attending physician. METHODS Patients undergoing DHC during 2005-2016 were identified using Current Procedural Terminology codes. Inclusion criteria were: operative note available in the electronic medical record and postoperative head computed tomography (hCT). Exclusion criteria were: age

Objectives We sought to make pathologists’ intraoperative consultation (IOC) results immediately available to the surgical team, other clinicians, and laboratory medicine colleagues to improve communication and decrease postanalytic errors. Methods We created an IOC report in our stand-alone laboratory information system that could be signed out prior to, and independent of, the final report, and transfer immediately to the electronic health record (EHR) as a preliminary diagnosis. We evaluated two metrics: preliminary (IOC) result review in the EHR by clinicians and postanalytic errors. Results We assessed 2,886 IOC orders from the first 22 months after implementation. Clinicians reviewed 1,956 (68%) of the IOC results while in preliminary status, including 1,399 (48%) within the first 24 hours. We evaluated 150 cases preimplementation and 300 cases postimplementation for discrepancies between the pathologist’s IOC result and the IOC result recorded by the surgeon in the operative note. Discrepancies dropped from 12 of 150 preimplementation to 6 of 150 and 7 of 150 in postimplementation years 1 and 2. One of the 25 discrepancies had a major clinical impact. Conclusions Real-time reporting of IOC results to the EHR reliably transmits results immediately to clinical teams. This strategy reduces but does not eliminate postanalytic interpretive errors by clinical teams.

Introduction Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid-19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients’ e-records which adhere to RCSEng guidelines. Method In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle. Results 261 patients were included in both study periods. Only 36/134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%). Conclusions Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of e-template was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.

OUTCOME OBJECTIVES STUDY DESIGN:: Retrospective chart review. SETTING Single tertiary care center, 2001 to 2016. PATIENTS Adult CI recipients were assessed. Inclusion required ≥1 revision surgeries, operative note(s), and postrevision follow-up of 6 months. INTERVENTIONS Therapeutic/rehabilitative. MAIN OUTCOMES MEASURES Indications for revision (HF, SF, WC, and MM) were tabulated. The incidence of each was compared between cohorts implanted before/after 2011. Additional outcomes included implant usage, explantation rates, and postrevision speech scores. RESULTS Four hundred thirty-two patients received 512 CIs. Of these, 30 patients required 38 revisions. Median time to revision was 24.5 months. Frequency by indication was HF (n = 14), SF (n = 12), WC (n = 8), and MM (n = 4). The overall revision rate was 7.4%. There was a significant decline in overall revisions for patients implanted before/after 2011 (10.4 versus3.5%; p = 0.009). No patients implanted after 2011 experienced a HF (p = 0.002). Patients with WC/MM had significantly shorter time to revision compared with patients with HF/SF (p = 0.04). The overall median follow-up was 24 months. Twenty-three of 30 patients are still using their revised CI. Patients revised for HF and MM achieved the best outcomes. CONCLUSION 7.4% of adult CI recipients required revision surgery. Explantation/immediate reimplantation was an effective management strategy. While HF was the most common indication overall, no patients implanted after 2011 have suffered this complication. The overall revision rate has significantly declined since 2011.

The operative note is a vital document in the treatment and safety of patients. Detailed recording of operation notes can be quite helpful in research, audit and medico-legal problems. This quality improvement programme was conducted to assess the quality of documentation on an electronic template in comparison to the Royal College of Surgeons (RCS) guidelines. The electronic template used for recording operation notes was compared with RCS guidelines for completeness. A retrospective review of operation notes for all the operations performed by ENT over 1-month period was done. The deficiencies were shared with the department during monthly quality-improvement meetings. A second cycle was carried out in the month of September. The electronic template that is being used in our hospital matches completely with the RCS recommendation. A total of 90 operative records were analysed in the initial audit. The Compliance was 100% in all parameters except five. In the second cycle of audit, compliance was found to be 100% across all parameters, except one—showing considerable improvement. Electronic templates offer easy recording of operation notes without the help of aide memoire, despite which deficiencies do occur. Regular audits are needed to maintain good record-keeping.

Introduction Mechanical thrombectomy is the treatment of choice for ischemic stroke due to large vessel occlusion. One common reason for failure or prolonged procedure time is vascular touristy inhibiting access to the site of occlusion. A novel device -the TracStar Large Distal Platform (LDP) -may offer improved navigation of tortuous vasculature as well as more distal final positioning when compared to commonly used guide catheters. We investigate the safety and efficacy of the TracStar LDP when used during mechanical thrombectomy. Methods We perform a multicenter retrospective review of mechanical thrombectomy procedures during which the TracStar LDP was utilized. Procedural information, complications, and key timepoints (groin puncture, clot-first-touch, etc.) were recorded as detailed in the operative note. Vascular tortuosity was assessed via pre-procedural CTA. Distal-most position achieved with TracStar was determined by review of intraprocedural imaging. Linear regression was performed to investigate the potential relationship between vascular tortuosity and procedure time. Results In a preliminary analysis of 20 cases, successful reperfusion (TICI 2b/3) was achieved in 88% of cases, requiring 1.8 passes on average (rage 1–5). Average NIHSS at presentation was 17.8 ± 6. Anterior circulation emboli were encountered in 15 cases. Average time to clot-first touch was 12± 7 minutes and average time to final reperfusion was 50 ± 27.6 minutes. Good functional outcome (mRS 0–2) at 90 days was achieved in 35% of cases. There was no association between vascular tortuosity and procedure time. There were no procedural complications, and TracStar LDP was exchanged for an alternative guide catheter in two cases due to failure to maintain positing. Conclusion Mechanical thrombectomy with the Tracstar LDP is safe and effective. Access beyond the horizonal petrous segment of the ICA was achieved in the majority of cases. Interestingly, ICA tortuosity was not associated with an increased time to clot-first-touched. Final analysis of 30 patients in this multi-center retrospective study will be available for presentation at the SNIS Annual Meeting 2020. Disclosures D. Bageac: None. R. De Leacy: None.

Introduction Increased procedure time during endovascular treatment of cerebral aneurysms is associated with increased anesthesia related complications and radiation exposure. Elimination of the need for intermediate catheters during aneurysm treatment may decrease procedure time and increase cost effectiveness. A novel device -the TracStar Large Distal Platform (LDP) -may offer more distal final positioning when compared to commonly used guide catheters, thus decreasing the need for guide catheter use. We investigate the safety and efficacy of the TracStar LDP when used during endovascular aneurysm treatment. Methods We perform a multicenter retrospective review of endovascular cerebral aneurysm embolizations during which the TracStar LDP was utilized. Aneurysm location, procedural information, and complications were recorded as detailed in the operative note. Vascular tortuosity was assessed via pre-procedural CTA. Distal-most position achieved with TracStar was determined by review of intraprocedural imaging. Results A preliminary analysis of 30 cases was performed. Flow diversion was performed in 25 cases (83%), and stent assisted coiling was performed in the remainder. The target aneurysm was located in the ICA in 27 cases (90%), the MCA bifurcation in 2 cases (7%), and the ACA in 1 case (3%). An intermediate catheter was required in 18 cases (60%). TracStar LDP achieved stable access to the Cavernous ICA in 70% of cases. Average procedure time was 67± 33 minutes.There were no procedural complications or new neurologic defects after treatment. TracStar LDP was exchanged for an alternative guide catheter in one case due to catheter kinking, and in two cases due to lack of support. Conclusion Use of Tracstar LDP during flow-diversion and sent-assisted coiling of cerebral aneurysms is safe and effective. Access to the cavernous segment of the ICA was achieved in the majority of cases, and use of an intermediate catheter was not required in 40% of cases. Final analysis of the the full 60 patient multi-center study will be available for presentation at SNIS Annual 2020. Disclosures D. Bageac: None. R. De Leacy: None.

Importance: All events that transpire during laparoscopic cholecystectomy (LC) cannot be adequately reproduced in the operative note. Video recording is already known to add important information regarding this operation. Objective: It is hypothesized that additional audio recordings can provide an even better procedural understanding by capturing the surgeons' considerations. Design, Setting, and Participants: The Simultaneous Video and Audio Recording of Laparoscopic Cholecystectomy Procedures (SONAR) trial is a multicenter prospective observational trial conducted in the Netherlands in which operators were requested to dictate essential steps of LC. Elective LCs of patients 18 years and older were eligible for inclusion. Data collection occurred from September 18, 2018, to November 13, 2018. Main Outcomes and Measures: Adequacy rates for video recordings and operative note were compared. Adequacy was defined as the competent depiction of a surgical step and expressed as the number of adequate steps divided by the total applicable steps for all cases. In case of discrepancies, in which a step was adequately observed in the video recording but inadequately reported in the operative note, an expert panel analyzed the added value of the audio recording to resolve the discrepancy. Results: A total of 79 patients (49 women [62.0%]; mean [SD] age, 54.3 [15.9] years) were included. Video recordings resulted in higher adequacy for the inspection of the gallbladder (note, 39 of 79 cases [49.4%] vs video, 79 of 79 cases [100%]; P

The operative note records surgical indication and pertinent events.In addition, it is a central facet in billing, malpractice lawsuits, research, and future medical planning. However, few residencies have structured education concerning dictation and there is little research on effective techniques for dictation training. The purpose of this study was to evaluate the efficacy of an educational intervention on the dictations of operative cases in which the residents were participants. Two hundred and eighty operative reports were reviewed for the presence or absence of criteria listed in Table 1 and given a score equal to the number of items included. One hundred and forty reports were evaluated before and 140 after an educational intervention. The intervention consisted of a lecture provided by a faculty expert while residents received an instructional card similar to Table 1 as a template. Primary endpoint was dictation score before and after the intervention. The pre- and postintervention scores for all residents were 16.28 and 17.37, respectively (P = 0.001). Junior and senior residents’ preintervention average differed by 1.18 (P < 0.001), however there was no significant postintervention difference. The four most commonly missed data points were the amount of intravenous fluids given, preoperative indications, intraoperative findings, and whether or not a drain was placed. This study used real operative reports to show the benefit of dictation templates for improving resident dictations. These data support previous studies on dictation templates and depict the benefits within one surgical program after implementing a formal plan for dictation education.

Rationale and Objectives Correlation of imaging studies and reference standard outcomes is a significant challenge in radiology. This study evaluates the effectiveness of a new communication tool by assessing the ability of this system to correctly match the imaging studies to arthroscopy reports and qualitatively assessing radiologist behavior before and after the implementation of this system. Materials and Methods Using a commercially available communication or educational tool and applying a novel matching rule algorithm, radiology and arthroscopy reports were matched from January 17, 2017 to March 1, 2017 based on anatomy. The interpreting radiologist was presented with email notifications containing the impression of the imaging report and the entire arthroscopy report. Total correlation rate of appropriate report pairings, modality-specific correlation rate, and the anatomy-specific correlation rate were calculated. Radiologists using the system were given a survey. Results Overall correlation rate for all musculoskeletal imaging was 83.1% (433 or 508). Low correlation was found in fluoroscopic procedures at 74.4%, and the highest correlation was found with ultrasound at 88.4%. Anatomic location varied from 51.6% for spine to 98.8% for hips and pelvis studies. Survey results revealed 87.5% of the respondents reporting being either satisfied or very satisfied with the new communication tool. The survey also revealed that some radiologists reviewed more cases than before. Conclusions Matching of radiology and arthroscopy reports by anatomy allows for excellent report correlation (83.1%). Automated correlation improves the quality and efficiency of feedback to radiologists, providing important opportunities for learning and improved accuracy.

BACKGROUND CONTEXT Medical notes contain a rich supply of medical data, yet the format of unstructured text precludes this data from being readily used by computers for data mining. Using natural language processing (NLP) in combination with machine learning on standard operative notes may allow for efficient billing, maximization of collections and minimization of coder error. PURPOSE We hypothesize that a machine learning algorithm can accurately identify billing CPT codes on unstructured patient operative notes. STUDY DESIGN/SETTING This was a retrospective analysis of medical notes from a large, single-center academic institution's database comprised of cases from a single surgeon. PATIENT SAMPLE Inclusion criteria included patients who underwent elective spine surgery by a single senior surgeon from 9/2015 to 1/2020. OUTCOME MEASURES Algorithm performance was measured by performing receiver-operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC). METHODS Inclusion criteria included patients who underwent elective spine surgery by a single senior surgeon from 9/2015 to 1/2020. Algorithm performance was measured by performing receiver-operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC). The data was randomized with 70% used for training and 30% used for testing. Labels (CPT codes) were generated by the billing and coding department. NLP (natural language processing) techniques were used to analyze standard operative notes and train an algorithm to automatically generate CPT codes. A deep learning NLP algorithm (bidirectional long short-term memory network with attention) was tested on operative notes to predict CPT codes. CPT codes generated by the billing department were compared to those generated by our model. RESULTS A total of 391 operative dictations fit our inclusion criteria. The NLP algorithm identified the correct CPT codes on the validation set with a final accuracy of 98%. The overall AUC was 80% for the top 36 CPT Codes. The average class by class accuracy for the top 36 CPT Codes was 80%. CONCLUSIONS Combining NLP with ML is a valid approach for automatic generation of CPT billing codes, and it can be used by departments to allow for efficient billing, maximization of collections and minimization of coder error. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background: Adequate preoperative planning is the first and most crucial step in the successful completion of a revision total joint arthroplasty. The purpose of this study was to evaluate the availability, adequacy and accuracy of operative notes of primary surgeries in patients requiring subsequent revision and to construct comprehensive templates of minimum necessary information required in the operative notes to further simplify re-operations, if they should become necessary. Methods: The operative notes of 144 patients (80 revision THA’s and 64 revision TKA’s) who underwent revision total joint arthroplasty at Stanford Hospital and Clinics in the year 2013 were reviewed. We assessed the availability of operative notes and implant stickers prior to revision total joint arthroplasty. The availability of implant details within the operative notes was assessed against the available surgical stickers for adequacy and accuracy. Statistical comparisons were made using the Fischer-exact test and a P-value of less than 0.05 was considered statistically significant. Results: The primary operative note was available in 68 of 144 revisions (47%), 39 of 80 revision THAs (49%) and 29 of 66 revision TKAs (44%, p = 0.619). Primary implant stickers were available in 46 of 144 revisions (32%), 26 of 80 revision THAs (32%) and 20 of 66 revision TKAs (30%, p = 0.859). Utilizing the operative notes and implant stickers combined identified accurate primary implant details in only 40 of the 80 revision THAs (50%) and 34 of all 66 revision TKAs (52%, p = 0.870). Conclusion: Operative notes are often unavailable or fail to provide the necessary information required which makes planning and execution of revision hip and knee athroplasty difficult. This emphasizes the need for enhancing the quality of operative notes and records of patient information. Based on this information, we provide comprehensive operative note templates for primary and revision total hip and knee arthroplasty.

INTRODUCTION The purpose of this study is to compare the utility and validity of the OrthoMiDaS (Orthopaedic Minimal Data Set) Episode of Care (OME) database with the current benchmark for recording procedural details, the operative note (OpNote), with regard to disease severity and risk factors for hip arthroscopy cases. METHODS A convenience sample of the first 100 hip arthroscopy cases for labral tears done at our institution between February and August 2015 were selected for this study. Surgeons recorded procedural details within OME after each case. An individual blinded to the OME data performed a chart review of the OpNote and/or implant log and recorded the information in a separate REDCap database. RESULTS OME demonstrated higher completion rates than the OpNote for important procedural details such as previous left and right hip surgery (P < 0.001), anchor type (P = 0.008), and labrum tear clockface variables (P < 0.001 for both). In addition, OME exhibited "near-perfect" agreement with the OpNote for several important procedural details such as surgical limb (Kappa = 1.000), suture configuration (Kappa = 0.982), repair type (Kappa = 0.947), tear clockface: from (Kappa = 0.949), and tear clockface: to (Kappa = 0.885). On average, surgeons took 117 seconds to complete data entry within OME. CONCLUSION The findings of this study validate the ability of OME to accurately and consistently capture important procedural details pertaining to arthroscopic hip surgery. Through the use of OME, high-quality standardized information can be captured and used to advance the field of hip arthroscopy by determining the clinically useful predictors of patient-reported outcome measures.

Cervical disc replacement (CDR) has a high success rate. However, failure may occur due to persistent radiculopathy or myelopathy, malposition, heterotopic ossification, infection, subsidence, bearing wear, sizing error, and vertebral body fracture. Preoperative planning prior to revision surgery requires a complete history and physical, operative note from the index surgery, identification of implant information, imaging (radiographs, CT, and/or MRI), and determination of the etiology of CDR failure. Explanting the device and performing a fusion with a cage or graft may be performed for one-level revision. Corpectomy and fusion should be considered for two or greater levels of CDR revision because it reduces the number of graft-bone interfaces that require fusion, provides a large amount of autograft, affords stability, and removes the fibrinous on growth that occurs under the baseplates from the original surgery. Revision is associated with a greater complication rate than primary CDR, and consideration must be given to mitigating factors that predispose to adverse events.

Context.—Intraoperative pathology consultation is an important tool for many surgical procedures and is deemed appropriate when the pathology result immediately alters surgical management.Objective.—To evaluate the utility of intraoperative gross examinations of colorectal resections and to better understand the associated costs.Design.—The pathology database of our institution was searched for colorectal resections for primary disease, and those cases were separated into 3 categories: frozen section performed, intraoperative gross examination performed, and no intraoperative consultation. We reviewed 270 cases during a 15-month period.Results.—Of the 270 cases, 200 (74.1%) had an intraoperative gross examination. In 34 of the 200 cases (17%), additional specimens were taken and, therefore, required operative note review to ascertain whether the additional specimens taken were based on the findings from the intraoperative gross examination. After reviewing the operative notes for those 34 cases, none (0%) were a result of the gross findings reported. The average associated time for intraoperative gross examinations was 27.67 minutes (including transport). The billable costs exceeded $7000 during the study period, and the cost of the pathology assistant's time per case was $22.10.Conclusions.—Our study demonstrates that no change in surgical management was a result of gross examination of colorectal resection specimens and that the associated costs were significant. Decreasing unnecessary consultations will directly save the health care system money by eliminating billable services and will also increase the efficiency of the pathology department by reducing the opportunity costs for the time of the pathologist and the pathology staff.

We evaluated the operative notes for justification on the use of the 22-modifier in ankle fracture cases and compared the differences in physician billing and reimbursement. A total of 265 patients who had undergone operative management of isolated ankle fractures across a 10-year period were identified at a level I trauma center through a retrospective chart review. Of the 265 patients, 61 (23.0%) had been billed with the 22-modifier. The radiographs were reviewed by 3 surgeons to determine the complexity of the case. The amount of the professional fees and payments was obtained from the financial services department. Operative reports were reviewed for inclusion of eight 22-modifier criteria and word count. Mann-Whitney U tests of means were used to compare cases with and without the 22-modifier. From our analysis of preoperative radiographs, 37 (60%) showed evidence of a significantly complex fracture that justified the use of the 22-modifier. A review of the operative reports showed that 42 (68%) did not identify 2 or more reasons for requesting the 22-modifier in the report. Overall, the 22-modifier cases were not always reimbursed significantly greater amounts than the nonmodifier cases. No significant difference in the average word count of the operative notes was found. We have concluded that orthopedic trauma surgeons do not appropriately justify the use of the 22-modifier within their operative report. Further education on modifiers and the use of the operative report as billing documentation is required to ensure surgeons are adequately reimbursed for difficult trauma cases.

Rationale, aims and objectives With expectations for standardization and evidence-based practice, the Royal College of Surgeons (RCS) published the ‘Good Surgical Practice’ in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico-legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma. Methods All general surgery and urology admissions during July 2011 and August 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in February 2012. Results were compared and statistically analysed using two-tailed Fisher's exact test, with Bonferroni correction where appropriate (SPSS 20.0, IBM SPSS Statistics, Armonk, NY, USA). Results There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistant's name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetist's name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% (P

Hypothesis We hypothesize that patients with a positive tangent sign will have rotator cuff tears that are not able to be repaired primarily. Methods We performed a retrospective review of the charts of patients who had undergone surgery for repair of a rotator cuff tear. The operative note was reviewed to determine whether the cuff tear was primarily repaired. The magnetic resonance imaging study of each patient was reviewed to assess for a positive or negative tangent sign. The reviewer was blinded to the result of each measurement. Results Eighty-one patients met the inclusion criteria. Of the 79 included in our analyses, 17 had a positive tangent sign and 62 had a negative tangent sign. There was only 1 patient with a negative tangent sign who had an irreparable rotator cuff tear. There were 3 patients with a positive tangent sign who had a repairable rotator cuff. With a pretest prevalence of irreparable tears of 18.9%, a positive finding suggested a post-test probability of 82.3% with a positive tangent sign and a post-test probability of only 1.6% when the tangent sign was negative. Conclusion Our results showed decision-making value in both a negative tangent sign and a positive tangent sign. The tangent sign is an easily performed and reproducible tool with good intraobserver and interobserver reliability that is a powerful predictor of whether a rotator cuff tear will be repairable.

Introduction: The purpose of the study was to assess the quality of documentation of knee arthroscopy and evaluate the implementation of a novel operative template. Method: A 34-point assessment was undertaken based on published national guidelines. A retrospective study of 50 operative notes of patients (group A) undergoing knee arthroscopy was completed. A new operative note template was devised to include important criteria and assessed in 49 patients (group B) for its efficacy in providing appropriately detailed findings. Results: Group A was lacking the minimum essential documentation standards expected. Some essential criteria for arthroscopic procedures were as low as 4%. Group B showed a statistically significant increase (P