Division of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA.
Surg Endosc. 2023 Nov;37(11):8846-8852. doi: 10.1007/s00464-023-10404-3. Epub 2023 Aug 28.
Accurate operative notes are imperative to patient care and are used for communication, billing, quality assurance, and medical-legal conflicts. However, operative note quality often varies and many lack critical details. Unfortunately, no standardized training exists in operative dictations for surgical trainees. This pilot study sought to determine resident ability to dictate a comprehensive operative note and to determine a need for a formal operative dictation curriculum.
Thirty-eight surgical residents between post-graduate years (PGY) one to four participated in a ventral hernia repair simulation. One senior (PGY3/4) resident coached two junior residents (PGY1/2). Residents completed an informal needs assessment regarding operative dictations. Post-simulation, residents completed an operative dictation. Notes were graded using a modified validated rubric.
Thirty-five residents completed the needs assessment, and 38 residents submitted an operative note. Eighty-two percent of this group have completed ≤ 25 operative dictations in training and 77% have received minimal feedback on operative dictations. Out of 33 total points, mean overall score was 18.9 ± 5.4 (Junior resident: 17.9 ± 5.4; Senior resident: 20.9 ± 4.8) Total mean scores did not significantly differ between junior and senior residents (p = 0.10). Senior and junior residents scored similarly on the procedural details component (p = 0.29). Senior residents scored higher on relevant patient history and operative note headers (p = 0.04).
Standard surgical training may not provide enough teaching and feedback to residents on operative note dictations. A formal residency training curriculum may bolster trainee ability to learn the components of an effective operative note.
准确的手术记录对患者护理至关重要，可用于沟通、计费、质量保证和医疗法律纠纷。然而，手术记录的质量往往参差不齐，许多记录缺乏关键细节。不幸的是，外科住院医师的手术记录没有标准化的培训。这项初步研究旨在确定住院医师是否有能力口述一份全面的手术记录，并确定是否需要正式的手术记录课程。
38 名住院医师（1 至 4 年住院医师）参加了腹疝修复模拟。一位高级住院医师（3/4 年住院医师）指导两位初级住院医师（1/2 年住院医师）。住院医师完成了一份关于手术记录的非正式需求评估。模拟结束后，住院医师完成了手术记录。使用经过修改的验证量表对记录进行评分。
35 名住院医师完成了需求评估，38 名住院医师提交了手术记录。这一组中有 82%的人在培训中完成了≤25 次手术记录，77%的人仅收到了少量手术记录反馈。在 33 个总分中，平均总分为 18.9±5.4（初级住院医师：17.9±5.4；高级住院医师：20.9±4.8）。初级和高级住院医师的总分没有显著差异（p=0.10）。初级和高级住院医师在手术细节部分的得分相似（p=0.29）。高级住院医师在相关患者病史和手术记录标题方面的得分更高（p=0.04）。
标准的外科培训可能没有为住院医师提供足够的手术记录教学和反馈。正式的住院医师培训课程可能会增强住院医师学习有效手术记录组成部分的能力。
