How much do standardized forms improve the documentation of quality of care?

Chart abstraction is a common method for measuring the quality of surgical care. In this study we examine how the use of standardized operative dictation and history forms improves documentation rates of bariatric quality measures.

Two independent reviewers evaluated 201 patient charts from two multi-surgeon bariatric surgery practices for documentation of five intraoperative and seven preoperative bariatric quality measures. Group 1 used fully standardized templates to dictate or collect both, while Group 2 did not. Documentation rates were compared between the groups.

Operative reports more consistently documented quality assessment information for cases where a dictation template was used versus where it was not (89% versus 58%, respectively, P < 0.001). The greatest discrepancies between the two groups were found in "exploration of the abdomen" (95% in Group 1 versus 43% in Group 2, P < 0.001) and in "evaluation of the gallbladder" (76% versus 28%, P < 0.001). In comparison, overall documentation rates for preoperative comorbidities were greater in both groups but remained higher for Group 1, who used fully standardized forms (98% versus 74%, P < 0.001). Group 1 had statistically significant higher rates of documentation for all seven comorbidities.

The use of standardized dictation templates and history forms is associated with significantly higher documentation rates of quality measures in bariatric surgery. The adoption of these methods into routine use will be needed to allow for wide scale quality assessment and improvement for surgical practices.