Surgical Education Structured operative reporting: a randomized trial using dictation templates to improve operative reporting Lawrence M. Gillman, M.D., M.Med. Ed., F.R.C.S.C. a, *, Ashley Vergis, M.D., M.Med. Ed., F.R.C.S.C. a , Jason Park, M.D., M.Ed., F.R.C.S.C. a,b , Sam Minor, M.D., F.R.C.S.C. c , Mark Taylor, M.D., M.Sc., F.R.C.S.C. a a Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; b Department of Surgery, University of Toronto, Toronto, Ontario, Canda; c Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada Abstract BACKGROUND: Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. METHODS: Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. RESULTS: There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02). CONCLUSIONS: The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations. © 2010 Elsevier Inc. All rights reserved. KEYWORDS: Surgical education; Dictated operative report; Quality assurance; Documentation The dictated operative report (OR) is a key form of surgical communication. It is a part of the patient’s med- ical record, documents the details of the procedure(s) performed, helps health care providers better understand patients’ medical histories, and may facilitate the provi- sion of additional health care. Indeed, the quality of care delivered may be hampered by poor communication. 1 Additionally, ORs play important roles in billing, quality assurance, research, and resolving medical-legal con- flicts. Despite its implications, evidence suggests that the qual- ity of dictated ORs in North America is poor. 2 It is common to find critical details of operative procedures omitted and unnecessary aspects detailed excessively. In a recent audit of selected operative dictations from a large North Ameri- can center, only 45.9% of consensus criteria could be re- trieved from ORs, whereas superfluous information was available in 97% of cases. 3 Supported by the Bell University Laboratory Fellowship for Research in Health Communication, University of Toronto, Toronto, ON and the Royal Col- lege of Physicians and Surgeons of Canada Medical Education Research Grant. Drs. Gillman and Vergis were supported by the R. Samuel McLaughlin/Manitoba Medical Service Foundation Research and Education Fellowship Award in Med- icine, University of Manitoba, Winnipeg, Manitoba, Canada. Presented as a poster at the Royal College of Physicians and Surgeons of Canada Annual Conference, September 27, 2007, Winnipeg, Manitoba, Canada, and the Association for Surgical Education Annual Conference, April 17, 2008, Toronto, Ontario, Canada. * Corresponding author. Tel.: +1-403-453-1831; fax: +1-403-944-8799. E-mail address: gillmanlm@yahoo.ca Manuscript received May 12, 2009; revised manuscript June 23, 2009 0002-9610/$ - see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2009.06.030 The American Journal of Surgery (2010) 199, 846 – 850