The practice of medicine depends on accurate communication among physicians, patients, families, and allied health personnel. The Accreditation Council of Graduate Medical Education has designated communication as one of the core competencies in residency education. A large component of this communication is in the form of written documentation by physicians, such as operative reports, discharge summaries, and letters to referring physicians and patients. After an operative procedure, it is imperative for the surgeon to immediately dictate the findings and key components of the case in an accurate and concise manner. Operative notes should be completed in a timely fashion, as required by the Joint Commission of Accreditation of Healthcare Organizations.1
Operative records can be used for a variety of reasons, including provision of additional medical care, planning future operative procedures, research projects, quality assurance, billing, and medical-legal conflicts. For example, in gynecologic oncology cases, the volume and location of tumor after cytoreductive surgery for ovarian cancer can affect therapeutic management. For endometriosis and infertility cases, it is important to provide accurate documentation of the location and severity of disease seen, as well as patency of the fallopian tubes. In obstetrics, the type of uterine incision can impact future delivery options. In addition, to bill third-party payors appropriately, key details and components must be present in the dictated operative report2; otherwise, reimbursement can be adversely affected. The legal implications of accurate operative notes are obvious, including the important positive and negative operative findings may influence the outcome of a medical-legal case.
Despite the importance of operative notes, it is not uncommon to find that the critical details of operative procedures are missing, whereas certain useless aspects of the procedure, such as the type of suture and needle used or the type of clamps used for each step of the procedure, are described in extensive detail. Before the present study, there were limited data regarding teaching and evaluating operative dictation. Cohen and Ammon3 developed an intervention based on a theoretical framework for behavioral change to reduce the number of undictated operative notes. Although the number of undictated operative notes declined by 92%, the quality of the operative notes was not assessed in this study. Based on a MEDLINE search of the literature between the years 1966 and 2003, there are no published data regarding the quality of operative notes or methods to provide education regarding them. Using the terms “medical records” and “surgical procedures, operative” and combining these terms, we identified 46 references, but none dealt with either quality assessment or teaching with regard to operative dictation in U.S. residency programs. We furthered our search using the terms “operative note,” “operative record,” and “operative diction,” but no references were found that addressed the above-noted topics. Based on the paucity of data regarding operative dictation, we conducted a study with the following objectives: 1) to determine the extent of formal training in U.S. residency programs in obstetrics and gynecology and 2) to develop a curriculum for teaching operative dictation to residents.
MATERIALS AND METHODS
A 1-page questionnaire (Appendix) was mailed to all U.S. Obstetrics and Gynecology residency program directors. The inclusion of all current residency programs was assured by obtaining the list from the American Board of Obstetrics and Gynecology. To obtain the highest response rate possible, second and third mailings of the questionnaires were sent out, with new letters requesting the participation of every program. Formal teaching was defined as the presence of didactic session(s) during residency training specifically pertaining to operative medical record keeping. All of the responses were entered into a computerized database, and descriptive statistics analyses were performed with SPSS 11.0 statistical software (SPSS, Chicago, IL). Institutional review board approval was obtained before initiation of this study.
A second part of the study involved showing a videotape of an abdominal hysterectomy and bilateral salpingo-oophorectomy to all of the residents in Obstetrics and Gynecology at the University of Iowa. Subsequently, the residents were asked to dictate a full operative note based on the videotape. Information that could not be intuitively gained from the videotape, such as the date of the procedure, was provided to the residents. One week later, all the residents participated in a 30-minute teaching session regarding operative dictation. During this session, the faculty discussed various key elements of operative notes and provided specific examples for accurate, but concise notes. Within 3–4 weeks of this formal teaching session, all residents viewed the same operative procedure and dictated another operative report. The pre- and post- teaching operative reports were evaluated by 2 of the authors (A.K.S. and B.J.V.). The evaluators were blinded with regard to the identity and level of training of the residents performing the dictation and whether the dictation was performed before or after the teaching session.
The criteria used to evaluate the operative dictation were developed by the authors of this study and are as follows: date of the procedure (2 points), personnel involved (2 points), pre- and postoperative diagnoses (2 points), procedure performed (2 points), blood loss and fluids replaced (2 points), indications for surgery (2 points), findings during the case (2 points), and the description of the procedure (6 points). The scores were entered into a database and statistical analyses were performed by using SPSS software. The mean scores among the residents, based on the level of training, were compared by using analysis of variance. The paired t test was used to compare the overall change in pre- and post-teaching scores in each class. Analysis of variance was used to compare the mean difference in scores between classes and to compare the post-teaching scores between classes. P < .05 was considered statistically significant.
Of the 270 surveys mailed, 198 responses were received for a 73% response rate. Only 23% of the residency programs reported having a formal teaching program for instructing residents on how to dictate operative reports. These programs reported using a variety of teaching methods, including templates of operative notes and lectures from attending physicians, senior residents, and medical records staff at orientation. The remaining 77% of the programs had either some informal instruction or no instruction regarding operative dictation in their residency program. Eighty-three percent of program directors felt that standardized templates with some formal instruction would be useful in teaching operative dictations during residency training.
Surveys were assessed for teaching with regard to other medical documentation, including discharge summaries, medical charting, patient letters, and referring physician letters. Seventy-seven percent of the program directors reported some level of instruction regarding discharge summaries, and 62% provide some instruction regarding medical charting. Only 27% of the programs reported providing instruction regarding patient letters, and 26% provided instruction regarding letters to referring physicians. Fifty-five percent of the residency program directors felt that accuracy was a problem in operative dictation. Furthermore, accuracy was reported as a problem by 47% of the program directors for discharge summaries, 46% for medical charting, 31% for letters to referring physicians, and 29% for letters to patients.
Another part of our questionnaire surveyed the potential impact of poor dictation on patient care. Thirty-three percent of the program directors were aware of specific instances in which medical care had been adversely affected by poor medical charting, and 26% reported that poor operative dictation had adversely affected medical care. Poor discharge summaries were thought to have a negative impact on medical care by 18% of responders and inadequate letters to referring physicians by 10%. Forty percent of the program directors responded that they knew of specific cases adversely affected by poor medical charting or poor dictation, with an average of 2.1 cases within the past year.
The second phase of the study was to develop and prospectively evaluate the impact of a formal teaching program regarding operative dictation. All 16 Obstetrics and Gynecology residents at the University of Iowa participated in this part of the study. The scores for the operative dictation, pre- and post-teaching for each class, are listed in Table 1. The mean of all of the residents’ preteaching scores was 9.06 ± 2.93. Before the didactic session, the mean scores ranged from 5.5 for the first-year class to 11.25 for the fourth-year residents. Using analysis of variance, the preteaching scores of the classes were compared and found to be significantly different (P = .009). The mean score of all residents after the teaching session was 18.56 (range: 17.50 for first-year residents to 18.75 for senior residents). The differences in scores between the classes after a formal teaching session were not significantly different (P = .11). Overall, based on the scores of the operative dictations, there was a significant improvement in the quality of operative dictation after a formal teaching session for all the residents (P < .001).
Accurate medical record keeping is an important skill that should be mastered by all physicians. Operative notes are particularly important to physicians who perform procedures. Unfortunately, the vast majority of training programs offer no didactic instruction in this important skill. We found that only 23% of Obstetrics and Gynecology residency programs have formal didactics in place for operative dictation. Producing an accurate and timely dictation after an operative case is imperative for providing good medical care to patients. Residency programs are designed to train physicians to become proficient in their respective fields, and most physicians have had minimal or no training in medical records before entering a residency program. Although medical records contain multiple important elements, including operative notes, written notes in the chart, and letters to referring physicians and patients, we focused on operative notes in this study because of their importance to our and other procedural specialties. There are heavy demands on residency programs with regard to incorporating a diverse curriculum for developing competent physicians. However, as illustrated by the present study, even a brief formal educational session regarding operative notes can be incorporated easily into the core teaching curricula, resulting in significant improvement in the quality of these notes. The durability of the improvement after such a teaching session is not known but would be worthy of future investigation. Although our study focused on operative notes, it is possible that problems in other areas of medical records may also improve with some level of formal education during residency training.
Very little has been published concerning teaching of dictation skills in residency programs. In a letter to the editor, Moore describes a survey that was distributed to 26 surgical residency program faculty and to the program directors of 52 randomly selected surgery programs (Moore RA. The dictated operative note: important but is it being taught [letter]? J Am Coll Surg 2000;190:639–40). Of those responding from each group, only 31% and 18%, respectively, reported formal instruction regarding operative dictation. Cohen and Ammon3 conducted a study to improve the timeliness of residents’ operative dictation and showed that timeliness of residents’ dictation can be improved significantly through educational sessions and incentive programs. However, according to our MEDLINE survey, there are no published data regarding the assessment of quality or methods for improving operative notes. We provide the first such formal evaluation of teaching with regard to operative dictation in U.S. residency programs.
The reasons for producing a timely, accurate operative dictation include legal, financial, and medical.2,4 In cases with intra- or postoperative complications, the operative report is frequently a crucial piece of evidence regarding liability. Therefore, each dictation should include any aspects of the surgery that were particularly difficult. In addition, any intraoperative steps taken to assess for possible problems (for example, administration of intravenous indigo carmine to ensure integrity of the ureters) should also be included. Simply stating that a procedure was performed in a routine fashion may minimize the actual intraoperative effort of the surgeon. In terms of financial considerations, all aspects of the operation should be listed in the operative note. For example, if significant time was spent working through dense adhesions, this should be described in sufficient detail to allow for reimbursement of an adhesiolysis.
Several program directors provided subjective comments regarding the importance of this often-neglected topic. Many responders stressed the importance of timeliness in improving accuracy of operative notes. A few other responders indicated that verbosity is as much a problem in operative dictation as accuracy because this can also increase the costs of transcription. In addition, it was reiterated in the comments that accurate dictation can indeed have a positive impact on the care of patients.
Based on the results of our work and other published studies, the key components of operative notes should include basic information, such as the identity of the patient and medical personnel involved, date of the procedure, specific pre- and postoperative diagnoses, procedure(s) performed, type of anesthesia, indications for surgery, estimated blood loss, type and volume of fluid replacement, types and location of catheters and drains, any complications, and the condition of the patient during and at the end of the procedure. 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. With regard to the description of the operative procedure, for most routine procedures, the description of the entry and closure should be succinct. Inclusion of unnecessary details (for example, types of clamps at each step, needle size, every suture type—unless this level of detail is important for specific types of procedures, such as urethropexy or a novel operative procedure) should be avoided. Similarly, the other portions of the operative procedure should be described succinctly but accurately. Procedures requiring extra effort, such as extensive lysis of adhesions, and the time required should be described because this may have implications for reimbursement. Furthermore, any preventive measures, such as testing the bladder by filling it with methylene blue, should also be recorded.
In summary, very few residency programs provide any formal education regarding operative notes to their residents. Formal teaching regarding operative notes can improve the quality of these dictations and may have multiple benefits, including enhancement of medical care.