Structured operative reporting: a randomized trial using dictation templates to improve operative reporting.
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.
Gillman
Lawrence M
LM
Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada. gillmanlm@yahoo.ca
Vergis
Ashley
A
Park
Jason
J
Minor
Sam
S
Taylor
Mark
M
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