1. Introduction
The operative report is an essential component of communication, patient care, and safety [1]. Elements required by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) include history of present illness (HPI), findings, techniques, and operative steps. This documentation has important implications in obstetrics as route and timing of future deliveries are often influenced by operative findings (i.e., adhesions or distorted anatomy), uterine incision type and uterine closure techniques described in a prior cesarean operative report [2].
Almost 80% of residency program directors surveyed agreed on the importance of the operative report, yet less than 20% of programs provide formal resident training [3]. Clarke-Pearson outlined the importance of a clear description of anatomic distortion and residual tumor, as this information is essential in the care of gynecologic oncology patients [4]. Since more than one-third of pregnancies are delivered via cesarean, the operative report has become increasingly important in obstetrics as well [3].
A quality improvement assessment at our institution showed 80% of resident generated cesarean operative reports were missing one or more JCAHO required elements. Our review was based on the standards set by the Canadian Association of General Surgeons and the Structured Assessment Format for Evaluating Operative Reports (SAFE-OR). The goal of this study was to review OBGYN resident generated operative reports for cesarean deliveries to determine adherence to these standards. An educational resident in-service was then conducted with the goal of addressing deficiencies and improving compliance with JCAHO requirements [5].
2. Materials/Methods
This retrospective chart review of cesarean operative reports was approved by the Hackensack Meridian Health institutional review board. A quality improvement assessment showed 80% of resident generated cesarean operative reports were missing one or more JCAHO-required elements. Our primary outcome was to examine deficiencies in resident generated cesarean operative reports. Our secondary outcome was to assess the impact of an educational resident in-service on operative notes. The study was conducted in three phases.
Phase 1: Operative notes were evaluated with a validated tool adapted from general surgery by reading through cesarean operative reports and noting included and omitted required elements from SAFE-OR worksheet. A pre-study evaluation was performed using these guidelines on 50 consecutive resident generated operative reports for cesarean deliveries using the data collection sheet provided by Vergis et al. (see Table 1). Segments were divided into structured elements, HPI, procedure aspects, findings, technique of resection/mobilization, limits of resection, technique of reconstruction, and closure technique. All resident generated cesarean operative notes from November 2019 to January 2020 were collected consecutively to achieve 50 charts.
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Table 1. Structured assessment elements.
Phase 2: Resident in-service educational program on the SAFE-OR standards for operative reports was conducted during resident didactics on 1/28/2020. The individual aspects of SAFE-OR were reviewed via printed handouts (see Table 1) for one hour while residents edited their personal operative report templates to include each required element.
Phase 3: Post-study evaluation on operative note adherence to SAFE-OR guidelines in same manner as phase 1. All resident generated cesarean operative notes from February 2020 to May 2020 were collected consecutively to achieve 50 charts. The pre and post study results were compared and assessed for improvement.
A sample size of 50 charts (N = 100) before and after the resident in-service was planned assuming an alpha of 0.05 with 80% to detect a 30% difference. Pre and post study results were compared using Chi square analysis with P value < 0.05. We used the Fisher Exact test when expected values were low.
3. Results
Pre and post in-service cesarean operative report evaluations were compared. Inclusion of date of surgery significantly improved from 78% to 100%, p-value < 0.001, inclusion of irrigation significantly improved from 20% to 72%, p-value < 0.001, and inclusion of history of presents illness (HPI) improved from 34% to 96%, p-value < 0.001. Non-significant improvement in the inclusion of comprehensive description of technique (72% to 86%, p-value 0.09) and inclusion of findings (94% to 100%, p-value 0.24) was noted.
We found no deficits in the following elements: date of dictation(p-value 1), patient identifiers (p-value 1), name of surgeons and assistants (p-value 1), name of anesthesiologist (p-value 0.49), preoperative diagnosis (p-value 1), postoperative diagnosis (p-value 1), procedure (p-value 1), type of anesthesia (p-value 1), skin preparation and draping (p-value 1), patient position (p-value 0.204), method of abdominal access (p-value 1), technique of resection (p-value 1), limits of resection (p-value 0.24), closure technique (p-value 1), estimated blood loss (p-value 0.49), sponge and instruments counts (p-value 1), and specimens sent (p-value 1). Elements not relevant to cesarean delivery (i.e. drains, implants, and prosthetics) were omitted from our analysis (Table 2).
4. Discussion
The operative report is an essential component of communication, patient care, and safety; it is a JCAHO requirement and legal document. Its purpose is to describe the procedure and operative findings in detail and helpguide physician decision making. JCAHO requires the operative note be completed immediately after the procedure and prior to transferring the patient to the next level of care to avoid omission of important details [6] [7].
Operative reports have become increasingly important in obstetrics. Eicholz et al. (2004) surveyed 270 U.S. Obstetrics and Gynecology residency program directors regarding the importance of operative reports completed by residents. Almost 90% of those surveyed responded that documenting anoperative report is an important skill to teach, yet only 23% of programs provide formal training. They also showed that a 30-minute teaching session could objectively improve operative reports [3].
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Table 2. Impact of Resident in-service on SAFE-OR elements, n = 100.
Moore (2000) surveyed 52 general surgery residency program directors about their operative report curriculum. Only 31% reported formal instruction during their own training [8]. Goodman (1983) commented that “even standard textbooks give little or no information to the young surgeon on the how, why and what is to be included in an operative report [7].” Those who had no formal instruction said they learned from reading notes of senior residents and attending physicians.
Given the overall importance of operative reports, an operative report curriculum should be part of formal resident training. Particular attention should be focused on inclusion of the HPI, operative technique (i.e. uterine incision type and closure) and anatomical findings. In addition, missing information in an operative report can negatively impact patient care. A report that lacks a description of uterine closure technique may dissuade a trial of labor after cesarean (TOLAC). The impact of operative reports on willingness to pursue or allow TOLAC requires further study. The importance of an operative report in reviews of care and in the defense of lawsuits cannot be overlooked.
Strengths of this study include the use of validated measures to quantify deficiencies and improvement, analysis powered to detect a 30% difference between pre and post resident in-service, and generalizability to other surgical specialties. A weakness of this study is that it was not powered to detect a significant difference in every aspect of the SAFE-OR assessment. Pre in-service deficiencies in some aspects were not as profound and therefore did not reach statistical significance. The 6.4% increase in documentation of operative findings and 19.4% improvement in documentation of technique, if confirmed in a larger sample, are clinically relevant improvements.
5. Conclusion
Our analysis shows that resident generated cesarean operative reports can be improved through an educational resident in-service. We believe that this essential documentation skill should be part of the curriculum in all OBGYN residencies with the goal of improving communication, patient care, and safety. We can do better!
Disclosures
The authors have nothing to disclose.