58. Stories - Structured operative reporting in enteric surgerys

L. M. Gillman, A. Vergis, J. Park, S. Minor, M. Taylor


The purpose of this study was to determine whether the introduction of a Standardized Operative Dictation Template improved the quality of resident dictation.
General surgery residents (N = 20) from the University of Manitoba participated in the study. All residents were shown a standardized surgical procedure video and then asked to dictate an operative report. Residents were randomized with the intervention group receiving the Operative Dictation Template. Three months later, all residents were retested. Resident comfort level with dictation and satisfaction with the template was evaluated with a questionnaire. Dictations were evaluated by two blinded independent reviewers using the previously validated SAFE-OR assessment tool. This tool consists of a Structured Assessment Form (SAF) scored out of 45 and a Global Quality Ratings Scale (GQRS) out of 36. Pre and post scores were analyzed using a two-tailed Wilcoxon signed rank test.
Subjective comfort level with dictation, as measured by responses on a five point Likert scale, improved significantly in the intervention group (p=0.02). In addition, 90% of residents in the intervention group subjectively reported their dictations improved because of the template. There was no overall difference in the quality of dictation in the intervention group pre and post intervention as measured by the SAF (28.6 vs. 30.0; p=0.36) and GQRS (21.7 vs. 21.8, p=0.96). However, junior resident subgroup analysis revealed statistically significant improvement in the intervention on both the SAF (23.2 vs. 28.3; p=0.02) and GQRS (17.1 vs. 20.4; p=0.02). Senior resident subgroup analysis showed no difference in the intervention group on either the SAF (36.8 vs. 32.4; p=0.07) and GQRS (28.5 vs. 23.9; p=0.07).
The Operative Dictation Template can result in a significant improvement in resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.
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DOI: http://dx.doi.org/10.25011/cim.v30i4.2819


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