Developing Information Content for the Documentation of Surgery Cancellation Reasons in Hospital Information System

Introduction: The cancellation of a surgery operation not only imposed too much expenditure on the healthcare system, but also waste lots of energy and time of patient and health care provider. The aim of this study was to assess reasons of surgery cancellation, and to provide a comprehensive list of cancellation reasons to implement in hospital information system for improving documentation. Method: This study is an applied-descriptive study which was conducted in two parts. In first part, all medical records of hospitalized patients in Shafa educational hospital during 6 months period which had been assigned a cancellation code based on ICD-10, were assessed. The data were collected through a researcher-made checklist and have been analyzed using SPSS.V18 software. The second part was literature review which provided a list of surgery cancellation reasons. To retrieve the relevant papers PubMed and Google Scholar databases were searched. Finally the results of two parts of the study were combined and a comprehensive list of surgery cancellation reasons was developed. Results: Of 7529 surgical operation, 1229 operations (16.4%) were cancelled. Most of the cancelled surgical operations were related to inappropriate patient’s clinical condition before surgery. Extracted cancellation reasons were categorized into 8 groups. Totally a list of 54 reasons for cancellation was developed. Conclusion: Precise documentation of surgery cancellation reasons in each health care institution in order to determine the reasons and plan to prevent them is essential. Designing an information system with proper information content can support the above mentioned issues.