Structured operative reporting: a randomized trial using dictation templates to improve operative reporting

Abstract Background Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. Methods Twenty residents dictated an OR based on a surgical procedure video. Residents were randomi...

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Bibliographic Details
Published in:The American journal of surgery 2010-06, Vol.199 (6), p.846-850
Main Authors: Gillman, Lawrence M., M.D., M.Med. Ed., F.R.C.S.C, Vergis, Ashley, M.D., M.Med. Ed., F.R.C.S.C, Park, Jason, M.D., M.Ed., F.R.C.S.C, Minor, Sam, M.D., F.R.C.S.C, Taylor, Mark, M.D., M.Sc., F.R.C.S.C
Format: Article
Language:English
Subjects:
Biological and medical sciences
Comfort
Communication
Current Procedural Terminology
Dictated operative report
Documentation
Education, Medical, Graduate
General aspects
General Surgery - education
Humans
Internship and Residency
Intervention
Laparoscopy
Likert scale
Manitoba
Medical Records - standards
Medical sciences
Outcome Assessment (Health Care)
Quality
Quality assurance
Quality Control
Statistics, Nonparametric
Studies
Surgeons
Surgery
Surgical education
Surgical instruments
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Summary:Abstract Background Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. Methods Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. Results There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group ( P = .02). Conclusions The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.
ISSN:0002-9610
1879-1883
DOI:10.1016/j.amjsurg.2009.06.030