TITLE:
Cesarean Operative Reports: We Can Do Better!
AUTHORS:
Sarah E. Goodheart, Jonathan D. Baum
KEYWORDS:
Cesarean, Documentation, Notes, Operative, Resident
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.11 No.2,
February
25,
2021
ABSTRACT: Background: The operative report is an essential component of
communication, patient care, and safety; it is a JCAHO requirement and legal
document. 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. Documentation has important implications in
obstetrics as route and timing of future deliveries are often influenced by
operative findings. Purpose: Examine completeness of cesarean operative
reports using a validated instrument adapted from general surgery. Assess the
impact of an educational resident in-service on the required elements and
documentation in resident generated cesarean operative reports. Methods: A quality improvement project identified significant deficiencies in resident
generated cesarean operative reports. We conducted a retrospective chart review
of cesarean operative reports from November 2019 to May 2020 at Jersey Shore
University Medical Center. Our study was conducted in three phases. In phase 1,
a cohort of cesarean operative reports was examined using a structured
evaluation tool. In phase 2, an educational resident in-service on
standardization of operative notes was provided. In phase 3, another cohort of
cesarean operative reports was examined using the same evaluation tool after
the resident in-service. Analysis for improvement was performed. Results: Fifty pre and post-in-service cesarean
operative report evaluations were compared (N = 100). Inclusion of date
of surgery significantly improved from 78% to 100%, p-value Conclusion: Cesarean operative reports can be improved through an educational resident
in-service.