Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence

Nadine C. Kassis, Jennifer C. Thompson, Anne M. Scheidler, Joanne Daggy, Douglass S. Hale

Research output: Contribution to journalArticle

Abstract

Objective: We aimed to assess documentation completeness of the operative record for mesh implanted at the time of midurethral sling surgery and to identify modifiable predictors of documentation completeness. Methods: A retrospective cross-sectional study of women with stress incontinence who underwent midurethral sling placement between January 2009 and December 2011 was conducted. Data from the dictated operative note and nursing operative record were extracted to determine if the specific mesh implanted during surgery was documented. The primary outcome was the rate of documentation of mesh implanted in the physician's dictated operative note and in the nursing record. Logistic regression was used to determine if any characteristics were associated with the rate of documentation while accounting for correlation of patients from the same dictating surgeon. Results: There were 816 surgeries involving the implantation of a midurethral sling during the study period. All surgeries were performed at 6 Indiana University hospitals. Fifty-two surgeons of varying specialties and levels of training dictated the operative notes. A urogynecologist dictated 71% of the operative notes. The rate of documentation completeness for mesh implanted in the physician's note was 10%. The rate of documentation completeness for mesh implanted in the nursing operative record was 92%. Documentation of mesh implanted in the physician's note was not significantly associated with the level of training, specialty, or year of surgery. Conclusions: Documentation completeness for specific mesh implant in the physician's note is low, independent of specialty and level of training. Nursing documentation practices are more rigorous. Postmarket surveillance, currently mandated by the Food and Drug Administration, may not be feasible if only the physician's note is available or if nursing practices are inconsistent. Development of documentation guidelines for physicians would improve the feasibility of surveillance.

Original languageEnglish (US)
Pages (from-to)43-45
Number of pages3
JournalFemale Pelvic Medicine and Reconstructive Surgery
Volume21
Issue number1
DOIs
StatePublished - 2015

Fingerprint

Suburethral Slings
Documentation
Nursing Records
Physicians
Nursing
United States Food and Drug Administration
Cross-Sectional Studies
Logistic Models
Guidelines

Keywords

  • Surgical documentation
  • Urogynecological mesh

ASJC Scopus subject areas

  • Obstetrics and Gynecology
  • Surgery
  • Urology

Cite this

Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence. / Kassis, Nadine C.; Thompson, Jennifer C.; Scheidler, Anne M.; Daggy, Joanne; Hale, Douglass S.

In: Female Pelvic Medicine and Reconstructive Surgery, Vol. 21, No. 1, 2015, p. 43-45.

Research output: Contribution to journalArticle

Kassis, Nadine C. ; Thompson, Jennifer C. ; Scheidler, Anne M. ; Daggy, Joanne ; Hale, Douglass S. / Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence. In: Female Pelvic Medicine and Reconstructive Surgery. 2015 ; Vol. 21, No. 1. pp. 43-45.
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abstract = "Objective: We aimed to assess documentation completeness of the operative record for mesh implanted at the time of midurethral sling surgery and to identify modifiable predictors of documentation completeness. Methods: A retrospective cross-sectional study of women with stress incontinence who underwent midurethral sling placement between January 2009 and December 2011 was conducted. Data from the dictated operative note and nursing operative record were extracted to determine if the specific mesh implanted during surgery was documented. The primary outcome was the rate of documentation of mesh implanted in the physician's dictated operative note and in the nursing record. Logistic regression was used to determine if any characteristics were associated with the rate of documentation while accounting for correlation of patients from the same dictating surgeon. Results: There were 816 surgeries involving the implantation of a midurethral sling during the study period. All surgeries were performed at 6 Indiana University hospitals. Fifty-two surgeons of varying specialties and levels of training dictated the operative notes. A urogynecologist dictated 71{\%} of the operative notes. The rate of documentation completeness for mesh implanted in the physician's note was 10{\%}. The rate of documentation completeness for mesh implanted in the nursing operative record was 92{\%}. Documentation of mesh implanted in the physician's note was not significantly associated with the level of training, specialty, or year of surgery. Conclusions: Documentation completeness for specific mesh implant in the physician's note is low, independent of specialty and level of training. Nursing documentation practices are more rigorous. Postmarket surveillance, currently mandated by the Food and Drug Administration, may not be feasible if only the physician's note is available or if nursing practices are inconsistent. Development of documentation guidelines for physicians would improve the feasibility of surveillance.",
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