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.