Surgical residents and the adequacy of dictated operative reports

Abstract

Introduction: The surgeon's clinical note has been previously shown to poorly reflect both physician-centered and patient-centered outcomes. We hypothesized that dictated operative reports do not adequately demonstrate surgeons' workload, preoperative involvement, clinical decision-making, or core competencies.

Materials and methods: We retrospectively reviewed operative reports in the month of January for the years 2007-2011. Operative reports were dictated by interns, residents (R1-R5), and surgical staff. All resident reports were approved by staff surgeons. We qualitatively assessed each for 15 items that encompassed physician-centered outcomes, patient-centered outcomes, and Joint Commission/Medicare-required fields. Groups were compared to each other with 1-way analysis of variance with Bonferroni correction.

Results: We reviewed 999 operative reports. Nearly every chart included an indication and preoperative and postoperative diagnoses. Only 57.3% listed whether or not there were any complications. Half recorded operative findings. The mean number of fields missed based on level of surgical training was R1: 4.83, R2: 4.46, R3: 3.68, R4: 3.35, R5: 3.29, and staff: 3.09. Interns and second-year residents missed significantly more data fields than upper-level residents and staff (P < 0.0001). Staff surgeons missed fewer data fields than third-year residents (P = 0.004). There was no statistical difference between R4, R5, and surgical staff (P > 0.999).

Conclusions: The dictated operative report does not accurately document preoperative surgeon involvement, clinical decision-making, maintenance of core competencies, or full compliance with Joint Commission regulations. Focused education and enhanced staff oversight of junior-level dictated operative reports might be required to improve quality.