A solution to the problem of undictated operative reports by residents

Cohen, Max M.; Ammon, Adelaide A.

doi:10.1016/s0002-9610(98)00236-0

Cited by 7 publications

(15 citation statements)

References 10 publications

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“…Operative reports have been found to be lacking in consistency, quality and completeness and are frequently dictated after a significant delay. 6,[17][18][19] In a study of 250 laparoscopic cholecystectomy ORs, Stewart and colleagues 6 showed that there was a large variation in the content of reports and that key elements, such as adequate dissection of the Calot triangle, were often omitted (present in 24.8% of ORs). Several studies have reported significant delays in the dictation of ORs: 55% were dictated more than 24 hours after surgery in one study 17 and 33% after more than 48 hours in another study.…”

Section: Discussionmentioning

confidence: 99%

“…Several studies have reported significant delays in the dictation of ORs: 55% were dictated more than 24 hours after surgery in one study 17 and 33% after more than 48 hours in another study. 18 Sixty-seven percent of delayed dictations (> 24h) in a study of resi dent dictations were noted to be incomplete. 19 Flynn and Allen 17 reported that incomplete description of surgical procedures led to delayed reimbursement in 76% of 550 ORs, which was the equivalent of $1 300 000.…”

Section: Discussionmentioning

confidence: 99%

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Quality of inguinal hernia operative reports: room for improvement

Grace¹,

Pooni²,

Forbes³

et al. 2013

CJS

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Background: Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. Methods:A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. Results:We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repairspecific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). Conclusion:Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.Contexte : Les notes opératoires (NO) servent à documenter officiellement les interventions chirurgicales. Elles sont indispensables à des soins optimaux aux patients, à l'imputabilité des médecins, à la facturation de leurs actes, à l'orientation de la recherche clinique et aux vérifications. Les notes narratives non standardisées sont souvent de piètre qualité et incomplètes. Nous avons voulu vérifier l'exhaustivité des notes opératoires narratives concernant les réparations d'hernies inguinales (RHI).Méthodes : Une équipe de 4 chirurgiens a créé une liste de vérification standardisée consensuelle comprenant 33 variables applicables à la RHI. Cinq chirurgiens experts des RHI ont classé ces éléments selon qu'ils leurs semblaient essentiels, préférables ou non essentiels. Nous avons passé en revue les NO des RHI ouvertes effectuées dans 6 hôpitaux universitaires.Résultats : Nous avons passé en revue 213 NO et nous avons exclus les NO concernant 7 hernies fémorales. Les réparations sans tension se sont révélées les plus communes (82,5 %) et la technique plug-and-patch a été la plus fréquente (52,9 %). Les résidents ont dicté 59 % des NO. Sur les 33 variables, 15 étaient considérées essentielles et en moyenne, 10,8 ± 1,3 ont été incluses dans les NO. Parmi les éléments qui laissaient à désirer, mentionnons : première réparation c. réparation récurrente (8,3 %), viabilité du g...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Quality of inguinal hernia operative reports: room for improvement

Grace¹,

Pooni²,

Forbes³

et al. 2013

CJS

View full text Add to dashboard Cite

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“…All such guidelines have similar standards (Table 1), but previous research has shown that these standards are not always upheld. The time frame between surgery and operative note writing (dictation) is often unclear, and the quality of the operative notes is variable and poor [14, 15, 17, 18, 20, 21]. …”

Section: Introductionmentioning

confidence: 99%

Evaluation of Operative Notes Concerning Laparoscopic Cholecystectomy: Are Standards Being Met?

2010

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BackgroundLaparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon’s operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC.MethodsNine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the “not described” items were performed.ResultsAll hospitals participated. Most notes complied with the Dutch guideline (52–69%); 19–30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient’s posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and two teaching hospitals complied significantly less with the guidelines.ConclusionsOperative notes do not always fully comply with the standards set forth in the guidelines published in the Netherlands. This could influence adjuvant treatment and future patient treatment, and it may make operative notes less suitable background for other purposes. Therefore operative note writing should be taught as part of surgical training, definitions should be provided, and procedure-specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.

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“…All abnormal operative findings, as well as pertinent normal findings, should be described (for example, normal appearance of appendix or liver during diagnostic laparoscopy). The specimens removed during surgery should be listed in the operative note 10,11 .…”

Section: Discussionmentioning

confidence: 99%

Facts about compliance of surgeons “An audit study of the quality of operation notes in the department of general surgery, King Faisal Hospital, Makkah, Saudi Arabia”

Elfaki¹,

Elhilu²

2009

Sud Jnl Med Sci.

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Background: An accurate, complete, legible medical record implies accurate, complete organized assessment and management of the patient. Operation notes as one of the important patient's medical records are often produced as evidence in medico-legal cases. In a court of law, that which is not written down may be perceived as never having occurred. Poorly written and illegible notes, along with the use of confusing abbreviations, are a common source of weakness in a surgeon's defense. Objectives: This audit was carried out mainly to assess and review the compliance and adhere of surgeon to existing operation guidelines sheet of ministry of health (form 15), and to enhance professionalism. Methodology: In this retrospective audit, 266 operation notes were reviewed in general surgical department of King Faisal Hospital, Makkah, Kingdom of Saudi Arabia, during a period of six months (January -June 2007). Because we have no standing ethical committee in our hospital the approval and permission were given by the administration for this study. Notes were scrutinized and reviewed for the quality, accuracy of patient's personal data, details of operation and name of surgeon, operating team, details of operation, swabs, instruments counts, as well as for the inclusion of unacceptable abbreviations. The standard operation sheet (form 15) guideline of Ministry of Health, Kingdom of Saudi Arabia, attached to the patient's file was used as a reference. Results: None of the notes were completely filled in this audit, some of important vital data of patients e.g. identification data were missed in (122 patients 45.9 %), and usage of non standardized abbreviations was found in 118 (44.4%). The types of the operation (emergency/elective) was recorded in 179 (67.3%) of all the operative notes. The time of the operation was recorded in 129 (48.5%) of the operative notes. Wound closure details were recorded in 153 (57.5%) of the notes and many other data like name of surgeon, anesthesiologists, type of anesthesia were variably missed. Conclusion:We conclude that a simple compliance to the attached operation note sheets can significantly improve the quality of the notes, continuity of care and potentially avoid medico-legal problems. There is an urgent need for revision and modification of form No: 15 operation sheet of Ministry of Health as well as introduction of computer database in operation notes. This should be an issue for the Faculty of Medicine, making the training of future surgeons more effective.

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A solution to the problem of undictated operative reports by residents

Cited by 7 publications

References 10 publications

Quality of inguinal hernia operative reports: room for improvement

Quality of inguinal hernia operative reports: room for improvement

Evaluation of Operative Notes Concerning Laparoscopic Cholecystectomy: Are Standards Being Met?

Facts about compliance of surgeons “An audit study of the quality of operation notes in the department of general surgery, King Faisal Hospital, Makkah, Saudi Arabia”

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