Standardizing the Operative Note: A Way to Improve the Quality of Data Collection to Optimize Patient Care

INTRODUCTION: The standard surgical operative note serves an essential role in documenting the details of an operation; however common key details of the operative note are often omitted. This study investigated the effectiveness of implementing a Laparoscopic Cholecystectomy (LC) specific, intraoperative data collection template directly in the electronic health record to be used as an addition to the standard dictated operative note. We hypothesized that intraoperative data collection would lead to a more complete operative report. METHODS: In this single center study, we retrospectively analyzed 211 operative notes prior to implementing an intraoperative template and 680 operative notes post template initiation. The data in the operative notes was then compared to the operative note template on seven selected variables. A chi-squared test for independence and a proportions test was used to assess the data and a significance was set to p \u3c 0.005. RESULTS: Intraoperative recording of the key data points increased documentation of five of the seven selected variables. Significantly more postoperative reports included information on stone spillage, the placement of drains, use of irrigation, intraoperative cholangiogram, and peri-operative antibiotics when completed with the template in comparison to the dictated operative report group without the intraoperative template, with a p \u3c 0.001. CONCLUSION: Our study demonstrates that “real time” collection of several predefined key data points significantly improves the accuracy and completeness of the standard operative note