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Related Concept Videos

SBAR II: Application of SBAR01:14

SBAR II: Application of SBAR

SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
SBAR I: Understanding the Concept01:29

SBAR I: Understanding the Concept

Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is...
Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Assessment of the Abdomen I: Inspection and Auscultation01:25

Assessment of the Abdomen I: Inspection and Auscultation

Introduction
The abdominal examination is a cornerstone of clinical medicine, serving as a critical tool in diagnosing various gastrointestinal (GI) diseases. It involves a systematic approach that includes inspection and auscultation, each with distinct yet complementary roles in assessing the abdomen. This article will delve into these two primary methods healthcare professionals use to examine the abdomen.
Inspection of the Abdomen
The first step in any abdominal examination is inspection.

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Related Experiment Video

Updated: Jul 9, 2026

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way
04:45

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Published on: May 10, 2021

Structured assessment format for evaluating operative reports in general surgery.

Ashley Vergis1, Lawrence Gillman, Samuel Minor

  • 1Section of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada. ashleyvergis@hotmail.com <ashleyvergis@hotmail.com>

American Journal of Surgery
|December 18, 2007
PubMed
Summary
This summary is machine-generated.

A new tool, the Structured Assessment Format for Evaluating Operative Reports (SAFE-OR), reliably assesses surgical dictation quality. It demonstrates construct validity and high reliability, aiding surgical education and curriculum refinement.

Related Experiment Videos

Last Updated: Jul 9, 2026

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way
04:45

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Published on: May 10, 2021

Area of Science:

  • Medical Education
  • Surgical Quality Assessment
  • Health Informatics

Background:

  • No validated tools exist to assess the quality of dictated operative notes.
  • Operative notes are crucial for patient care, communication, and legal documentation.
  • This study addresses the need for a reliable instrument to evaluate operative report quality in general surgery.

Purpose of the Study:

  • To determine the construct validity, interrater reliability, and internal consistency of the Structured Assessment Format for Evaluating Operative Reports (SAFE-OR).
  • To provide an objective tool for assessing the quality of dictated operative notes.
  • To support the development and refinement of surgical dictation skills training.

Main Methods:

  • The SAFE-OR instrument was developed using consensus criteria from the Canadian Association of General Surgeons.
  • It comprises a structured assessment and a global quality rating scale.
  • Novice and experienced surgical residents dictated a videotaped laparoscopic sigmoid colectomy, with blinded faculty evaluating transcribed reports using SAFE-OR.

Main Results:

  • Twenty-one residents participated; novice residents scored significantly lower than experienced residents on both structured assessment (23.3 vs 34.1) and global quality (25.6 vs 35.9) scales.
  • Excellent interrater reliability was found: Interclass correlation coefficients were 0.98 for structured assessment and 0.93 for global quality.
  • High internal consistency was demonstrated, with Cronbach's alpha coefficients of 0.85 for structured assessment and 0.96 for global quality.

Conclusions:

  • The SAFE-OR tool exhibits significant construct validity, excellent interrater reliability, and high internal consistency.
  • SAFE-OR enables objective evaluation of trainee operative report quality.
  • This instrument facilitates the implementation, monitoring, and refinement of dictation skills curricula in surgical education.