Resident Operative Reports before and after Structured Education

The operative note records surgical indication and pertinent events.In addition, it is a central facet in billing, malpractice lawsuits, research, and future medical planning. However, few residencies have structured education concerning dictation and there is little research on effective techniques for dictation training. The purpose of this study was to evaluate the efficacy of an educational intervention on the dictations of operative cases in which the residents were participants. Two hundred and eighty operative reports were reviewed for the presence or absence of criteria listed in Table 1 and given a score equal to the number of items included. One hundred and forty reports were evaluated before and 140 after an educational intervention. The intervention consisted of a lecture provided by a faculty expert while residents received an instructional card similar to Table 1 as a template. Primary endpoint was dictation score before and after the intervention. The pre- and postintervention scores for all residents were 16.28 and 17.37, respectively (P = 0.001). Junior and senior residents' preintervention average differed by 1.18 (P < 0.001), however there was no significant postintervention difference. The four most commonly missed data points were the amount of intravenous fluids given, preoperative indications, intraoperative findings, and whether or not a drain was placed. This study used real operative reports to show the benefit of dictation templates for improving resident dictations. These data support previous studies on dictation templates and depict the benefits within one surgical program after implementing a formal plan for dictation education.