Effects of a surgical case review handbook on chart documentation

The study results demonstrated statistically significant improvement in chart documentation after handbook distribution for the residents (t = 5.67, p.05). Improvement was made in the attending group after distribution of the handbook relative to documentation, but it was not statistically significant. The attending physicians showed a reduction of 1.2 percent in the mean percentage of documentation errors per month after use of the handbook, whereas the residents showed a reduction of 5.0 percent. The new residents (first-year) reached levels of chart documentation comparable to the more senior residents (second- and third-year) within three months after handbook distribution. During the study period, no interventions or efforts were made other than distribution of the handbook. Therefore, it can be concluded that the handbook produced an improvement in chart documentation compliance for all physicians, with a statistically significant effect for the resident physicians. The results indicate a high potential benefit for the first-year residents in particular.