Structured operative reporting: a randomized trial using dictation templates to improve operative reporting

Am J Surg. 2010 Jun;199(6):846-50. doi: 10.1016/j.amjsurg.2009.06.030.


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.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Current Procedural Terminology
  • Education, Medical, Graduate
  • General Surgery* / education
  • Humans
  • Internship and Residency*
  • Manitoba
  • Medical Records / standards*
  • Outcome Assessment, Health Care*
  • Quality Control*
  • Statistics, Nonparametric