Precise operative reporting is important to patient care, accuracy in billing, and trainee education. Although operative reports are the best way to understand the type of procedure a patient has had in the past, inaccurate transcription, incomplete information, and delayed completion of these reports often hampers the quality of the medical record. Hospital billing also relies on these records, so revenue may be lost if required components are missing. From an educational standpoint, trainees use dictated reports to learn the steps of procedures prior to performing them. If errors, inaccuracies and omissions are present, learning may suffer. Past studies have demonstrated that dictation templates decrease the number of inaccuracies, insufficient documentation, and allow for more prompt completion of reports.
A standardized template including pertinent, required items for all operative reports was organized in a standard format. Operative reports for all common Urogynecologic surgeries performed by all attending providers in the Female Pelvic Medicine and Reconstructive Surgery Division were collected. The technique for each procedure was detailed, taking care to include commonly missed or incompletely dictated items found during the review of dictated reports. After the template for the base surgery was created, additional dot phrase add-in procedures, such as perineorrhaphy or cystoscopy were created to easily add common concomitant procedures. Each procedure ended with an affirmation that an attending surgery was present for the entire procedure to avoid deficiencies in billing.
A basic blank template was created in addition to 23 full surgical template dictations. An index of procedural add-ons was created so that short dot phrase procedures could be added as needed. The dictation manual was compiled, added to common access for the division, and sent to each division member in a modifiable to allow all to use and adapt to their specific operative styles. Resident physicians were also given access to the manual to improve their understanding of procedures prior to assisting or performing these procedures.
Standardization of universal components of operative reports may improve compliance with billing, accuracy of reporting, and trainee understanding of procedures.
Barnes, K Lauren. "Dictation Templates for Surgical Learning and Improved Operative Reporting." (2020). https://digitalrepository.unm.edu/hsc_qips/33
Presented at the University of New Mexico Health Science 2020 Annual Quality Improvement and Patient Safety Symposium