• Am. J. Surg. · Jun 2010

    Randomized Controlled Trial

    Structured operative reporting: a randomized trial using dictation templates to improve operative reporting.

    • Lawrence M Gillman, Ashley Vergis, Jason Park, Sam Minor, and Mark Taylor.
    • Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada. gillmanlm@yahoo.ca
    • Am. J. Surg. 2010 Jun 1; 199 (6): 846-50.

    BackgroundFew 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.MethodsTwenty 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.ResultsThere 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).ConclusionsThe operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.Copyright 2010 Elsevier Inc. All rights reserved.

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