Volume 200, Issue 5 , Pages e16-e17, May 2009
Laparotomy operative note template constructed through a modified Delphi method
Article Outline
Objective
An operative note is indispensable to physician documentation and decision-making; however, there are no accepted standards for operative note content. Our aim was to use a modified Delphi consensus-building method to construct a uniform operative note template for laparotomy.
Study Design
Using Joint Commission on Accreditation of Healthcare Organizations requirements, literature review, and feedback from 15 medical malpractice defense attorneys, we compiled a draft operative note template of 31 elements. We surveyed 37 Association of Professor of Gynecology and Obstetrics/Solvay scholars asking for their input on inclusion of each item as essential content of the operative note.
Results
Two iterations of the survey were required to reach a predetermined 75% level of consensus. Nine elements were eliminated from the template: 6 original and 3 expert-suggested elements.
Conclusion
We provide an operative note template that was compiled through a Delphi process.
Key words: Delphi method, laparotomy operative note
An operative note is indispensable to physician documentation and decision-making. It also serves legal defense, billing, quality assurance, and research functions. There is little guidance on operative note content in the medical or legal literature. Consequently, a wide variety of formats, each of which reflect the culture and preferences of the hospital, practice, or surgeon who uses it, are currently in use.
Although the Joint Commission on Accreditation of Healthcare Organizations identifies requirements for an operative note, the requirements are minimal: preoperative diagnosis, postoperative diagnosis and findings, name of surgeon and assistants, specimens removed, estimated blood loss, and description of each procedure.1 A survey of Academic Obstetrics and Gynecology Programs in the United States found that only 10% of the requirements included formal didactic content about components of an operative note. However, most program directors favored instituting formal guidelines for consistency in educational expectations.2
When published data are inadequate, the Delphi method is a well-described tool to derive quantitative estimates through a qualitative approach. Consensus is reached through objective survey data that are gathered from experts, which avoids undue interpersonal influence from deeply invested individuals. Our goal was to build a template for operative note dictation using the structured, iterative modified Delphi method.3
Materials and Methods
This study was deemed exempt by the institutional review board. A draft of content for an operative note template was compiled from items that are required by Joint Commission on Accreditation of Healthcare Organizations and elements that are suggested in the literature.3, 4 This draft was then circulated to 15 experienced medical malpractice defense attorneys in southeastern Michigan. Attorneys were asked to provide input about their level of agreement, on a 9-point Likert scale, that an item was essential content in an operative note and to recommend other items that they deemed missing. Responses were incorporated into the template draft.
According to the Delphi method, we identified a group of experts, which was defined as 20-40 individuals from diverse geographic regions, to provide broad representation of expert judgment.3 We chose our panel from the 2004 and 2005 classes of the Association of Professor of Gynecology and Obstetrics/Solvay Scholars Program, with its rigorous application and peer review selection process.
Establishment of the acceptable level of consensus before initiation of the Delphi process is related to the importance of the research question.3 Because operative note content is significant to patient welfare, consensus was defined as ratings in the strongly agree range of 7-9 on a 9-point Likert scale by 75% of the expert respondents.
The draft template was distributed electronically by a web-based interface for creating and publishing custom web surveys (SurveyMonkey; 1999-2008, Portland, OR). Experts were asked to rate each item for inclusion on a 9-point Likert scale. They were also invited to add components that they considered missing in the list of items. Responses from the first survey iteration were collated and redistributed to each participant, along with group and individual responses. In the second iteration, scholars were asked to reconsider their initial responses in light of the group results. If consensus was not achieved, then items without consensus were rejected.
Results
Data were downloaded from SurveyMonkey into a secure Excel file (Microsoft Corporation, Redmond, WA). Frequencies of ratings were reported. Thirty-seven scholars received the first survey iteration; 23 scholars (62%) responded. Twenty-four of the 31 items (77.4%) achieved consensus ratings. Twenty-one scholars (91.3%) responded to iteration 2 of the survey. Three additional items achieved consensus. The Table displays the recommended components of a laparotomy operative note. Elements that lacked consensus on both iterations were eliminated from the template, which included a summary of what led the patient to the operating room, a statement of informed consent, examination with anesthesia, comment on entry into abdomen, the clamps that were used, suture that was used on pedicles, time out for patient verification, intravenous fluids that were administered, and urine output.
TABLE. Delphi technique consensus for laparotomy operative note items
| Operative note content | Iteration 1a (n) | Iteration 2b (n) |
|---|---|---|
| Patient identity | 23 (100%)c | |
| Procedure date | 22(95.7%) | |
| Preoperative diagnoses | 23(100%) | |
| Postoperative diagnoses | 23(100%) | |
| Surgeon & assistants | 23(100%) | |
| Procedure | 23(100%) | |
| Indications for surgery | 18(78.2%) | |
| Anesthesia | 22(95.7%) | |
| Operative findings | 23(100%) | |
| Description of the pelvis | 22(95.7%) | |
| Patient positioning | 19(82.6%) | |
| Incision type & placement | 22(95.7%) | |
| Anatomic landmarks | 19(82.6%) | |
| Procedure steps | 19(82.6%) | |
| Preventive measures | 21(91.3%) | |
| Estimated blood loss | 23(100%) | |
| Catheters/drains | 23(100%) | |
| Specimen removed | 21(91.3%) | |
| Suture used in closing abdomen | 18(78.2%) | |
| Complications | 23(100%) | |
| Rationale for response to complications | 23(100%) | |
| Consultants | 23(100%) | |
| Condition of patient at end of procedure | 22(95.7%) | |
| Hemostasis statement | 19(82.6%) | |
| Comment on abdomen closure | 15(65.2%) | 17(80.9%) |
| Presence of attending physician throughout case | 16(76.1%) | |
| Sponge/needle/instrument counts correct & verified | 19(90.4%) |
an = 23; |
bn = 21; |
cNumber in parentheses represents the percentage of consensus. |
Comment
We provide an operative note template that was compiled through a Delphi procedure that included input from both physicians and malpractice attorneys for use at various institutions throughout the country.
References
- . Comprehensive accreditation manual for hospitals: the official handbook 2008. Chicago: Joint Commission on Accreditation of Healthcare Organizations; 2008;
- . Teaching operative dictation: a survey of obstetrics/gynecology residency program directors. J Reprod Med. 2003;48:850–852
- . Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53:205–212
- . Operative note dictation: should it be taught routinely in residency programs?. Obstet Gynecol. 2004;103:342–346
This study was supported by a Grant from the St. Joseph Mercy Hospital Research Committee.
The findings of this study have been presented at the following meetings: Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics, Buena Vista, FL, poster presentation, March 5, 2008; 14th Annual Research Forum, St. Joseph Mercy Hospital, Ann Arbor, MI, April 22, 2008; and University of Michigan Health System 23rd Annual Abram Sager, MD, Lectureship & Senior Resident Research Paper Presentations, Ann Arbor, MI, May 14, 2008.
PII: S0002-9378(08)00879-X
doi:10.1016/j.ajog.2008.07.061
© 2009 Mosby, Inc. All rights reserved.
Volume 200, Issue 5 , Pages e16-e17, May 2009
