Currently, operative reports are narrative and often handwritten, making interpretation difficult and potentially omitting key steps of the procedure. This study undertook a systematic review to determine the current availability of synoptic operative reporting and develop a synoptic operative record template for emergency laparotomy (EL). A PROSPERO registered study from January 1st, 2012, to December 31st, 2022, was conducted using PubMed, Scopus, and Web of Science databases in February 2023. Keywords: emergency laparotomy AND operation notes OR operative notes OR documentation OR report OR pro forma OR narrative OR synoptic OR digital OR audio-visual. Studies on paediatric or pregnant patients, systematic reviews, meta-analyses, case reports, editorial comments, and letters were excluded. A synoptic operative record was designed to include key standards in the documentation, as suggested by the Colleges of Surgeons. The literature search yielded 4687 articles, and no relevant published articles were found. A detailed synoptic template was developed, which included 111 fields related to patient demographics, operative findings, interventions, and documentation of key variables associated with patient outcomes. 11 were text boxes, two were related to digital audio-visual uploads, and three facilitated the digital scoring/grading of findings. This systematic review identified a limited number of publications reporting synoptic operative reporting, and none related to emergency laparotomy. This novel operative template provides a platform for clear documentation of the surgery performed during emergency laparotomy, potentially facilitating data analysis, resident training, and research, in turn leading to a better understanding of patient outcomes.

中文翻译：

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加强紧急剖腹手术的手术记录：系统回顾和开发概要报告模板


目前，手术报告是叙述性的，并且通常是手写的，这使得解释变得困难，并且可能会省略手术的关键步骤。本研究进行了系统回顾，以确定当前概要手术报告的可用性，并开发了紧急剖腹手术 (EL) 概要手术记录模板。一项 PROSPERO 注册研究从 2012 年 1 月 1 日到 2022 年 12 月 31 日，于 2023 年 2 月使用 PubMed、Scopus 和 Web of Science 数据库进行。关键词：紧急剖腹手术 AND 手术笔记 OR 手术笔记 OR 文件 OR 报告 OR 形式 OR叙事或概要或数字或视听。针对儿科或孕妇的研究、系统评价、荟萃分析、病例报告、编辑评论和信件被排除在外。根据外科医生学院的建议，概要手术记录的设计目的是在文件中包含关键标准。文献检索共4687篇，未找到相关发表文章。开发了详细的概要模板，其中包括与患者人口统计、手术结果、干预措施以及与患者结果相关的关键变量的记录相关的 111 个字段。 11 个是文本框，两个与数字视听上传相关，三个用于对调查结果进行数字评分/分级。这项系统综述确定了数量有限的报告概要手术报告的出版物，并且没有与紧急剖腹手术相关的出版物。这种新颖的手术模板为紧急剖腹手术期间进行的手术提供了清晰的记录平台，有可能促进数据分析、住院医师培训和研究，从而更好地了解患者的治疗结果。