Prospective, Blinded Evaluation of Template-Based Cesarean Documentation Error in an Obstetric Training Program

Cesarean operative report accuracy impacts postoperative care and future obstetric decision-making. The impact of electronic health record template use on cesarean documentation error remains unknown. The aim of the study was to describe the incidence of resident physician documentation error in cesarean operative reports using electronic health record templates.

Attending physicians completed a standardized audit form after cesarean deliveries, which was compared with the resident operative report. Resident physicians were blinded to the auditing process. Errors were classified as none, major, or minor using predefined definitions. Author and operative characteristics were collected for comparative and predictive analyses. Data were analyzed by presence or absence of error.

We reviewed 100 cesarean operative reports. Major and minor errors were encountered in 33% and 53% of operative notes, respectively. Advancing training level was associated with lower incidence of major error (50%, for postgraduate year [PGY] 1, 33% for PGY 2, and 0% for PGY 3/4, P = 0.02), but minor errors were similar among training level, P = 0.48. Operative duration, documentation interval, and shift characteristics were similar in cases with and without documentation errors. In multiple logistic regression, PGY was predictive of major documentation error (adjusted odds ratio = 0.39, 95% confidence interval = 0.17-0.92).

A high incidence of clinically significant documentation error was observed in a residency training program using standardized templates for cesarean operative reports. Incidence of major error decreased with increasing training, but minor error was similar across levels of training. These data suggest that measures should be taken to improve documentation accuracy in medical training to provide optimal obstetric care.