Differences between attendings' and residents' operative notes for laparoscopic cholecystectomy

Area of Science:

• Surgical Quality Improvement
• Medical Documentation Standards
• Patient Safety Research

Background:

• Operative notes are crucial for detecting adverse events and informing scientific research.
• Accurate, complete, and objective operative notes are essential for safe patient care.
• This study investigates operative note-writing practices for laparoscopic cholecystectomy (LC).

Purpose of the Study:

• To compare the content of operative notes written by attending surgeons and surgical residents for LC.
• To identify differences in the level of detail and information included in notes.
• To assess the adequacy of current operative note generation systems.

Main Methods:

• Surgical residents and attendings reviewed video footage of three LCs.
• Participants dictated or typed corresponding operative notes.
• Notes were analyzed for the inclusion of specific items; Fisher's exact tests were used for statistical analysis.

Main Results:

• Residents included significantly more specific procedural details than attendings.
• Key areas where residents excelled included trocar placement, peritoneal opening, Critical View of Safety, and gallbladder removal site.
• Complications, such as gallbladder perforation, were underreported in all notes.

Conclusions:

• Surgical residents provided more comprehensive operative notes than attending surgeons in this LC study.
• A significant lack of detail regarding procedural complications renders notes subjective and incomplete.
• Procedure-specific templates or black-box systems based on guidelines are recommended to improve note quality.