Laparotomy operative note template constructed through a modified Delphi method.
OBJECTIVE
An operative note is indispensable to physician documentation and decision-making; however, there are no accepted standards for operative note content. Our aim was to use a modified Delphi consensus-building method to construct a uniform operative note template for laparotomy.


METHODS
Using Joint Commission on Accreditation of Healthcare Organizations requirements, literature review, and feedback from 15 medical malpractice defense attorneys, we compiled a draft operative note template of 31 elements. We surveyed 37 Association of Professor of Gynecology and Obstetrics/Solvay scholars asking for their input on inclusion of each item as essential content of the operative note.


RESULTS
Two iterations of the survey were required to reach a predetermined 75% level of consensus. Nine elements were eliminated from the template: 6 original and 3 expert-suggested elements.


CONCLUSIONS
We provide an operative note template that was compiled through a Delphi process.
Moore
Lolonya
L
St. Joseph Mercy Hospital, Department of Obstetrics and Gynecology, Ann Arbor, Michigan 48197, USA. OlearySh@trinity-health.org
Churley-Strom
Ruth
R
Singal
Bonita
B
O'Leary
Sharon
S
D003697:Delphi Technique; D004282:Documentation / Q000592:standards*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D007813:Laparotomy; D008318:Malpractice; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards*; D009774:Obstetrics; D011247:Pregnancy; D014481:United States