Electronic templates versus dictation for the completion of Mohs micrographic surgery operative notes.
BACKGROUND
Operative notes can be generated electronically by manual input of the entire note, free-form oral dictation, or using either an electronic template or a template for dictation. There are few studies that have directly compared these modalities in terms of speed, accuracy, and completeness.


OBJECTIVE
The objective was to determine whether electronic templates are more efficient and reduce errors compared to free-form oral dictation for the completion of Mohs micrographic surgery operative notes.


METHODS
Operative notes for 110 consecutive Mohs micrographic surgery cases were completed either by oral dictation or by electronic template. The time to dictate or complete the template was recorded for each note. Notes were subsequently edited, recording the number and type of errors as well as the time required to edit each note.


RESULTS
Compared with dictation, operative notes completed with the electronic template had fewer errors (5.8% vs. 81%), took less time to complete (175.5 seconds vs. 240.0 seconds), took less time to review and edit (41.6 seconds vs. 201.1 seconds), and were completed and signed in a more timely fashion (0.115 days vs. 20.7 days).


CONCLUSIONS
Electronic templates are a more accurate and rapid method compared to free-form oral dictation for the completion of Mohs micrographic surgery operative notes and have the advantage of being immediately available to review and sign.
Cowan
David A
DA
Department of Dermatology, The Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA.
Sands
Mandy B
MB
Rabizadeh
Susan M
SM
Amos
Charles S
CS
Ford
Carolyn
C
Nussbaum
Rachel
R
Stein
David
D
Liegeois
Nanette J
NJ
D004526:Efficiency; D005568:Forms and Records Control / Q000379:methods*; D006801:Humans; D007396:Internship and Residency; D008396:Maryland; D016347:Medical Records Systems, Computerized / Q000191:economics / Q000592:standards*; D008505:Medical Staff, Hospital; D015580:Mohs Surgery; D009870:Operating Room Information Systems / Q000592:standards*; D017063:Outcome Assessment, Health Care; D012878:Skin Neoplasms / Q000601:surgery*; D013996:Time and Motion Studies; D014941:Work Simplification