title: 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 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.
authors.affiliation: Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada. gillmanlm@yahoo.ca
authors.forename: Lawrence M
authors.initials: LM
authors.lastname: Gillman
authors.forename: Ashley
authors.initials: A
authors.lastname: Vergis
authors.forename: Jason
authors.initials: J
authors.lastname: Park
authors.forename: Sam
authors.initials: S
authors.lastname: Minor
authors.forename: Mark
authors.initials: M
authors.lastname: Taylor
mesh_terms: D039702:Current Procedural Terminology; D004503:Education, Medical, Graduate; D013502:General Surgery / Q000193:education; D006801:Humans; D007396:Internship and Residency; D008350:Manitoba; D008499:Medical Records / Q000592:standards*; D017063:Outcome Assessment, Health Care; D011786:Quality Control; D018709:Statistics, Nonparametric