Technically Speaking: Operative Reports

First things first: I’m sorry.

I’m sorry for changing your dictated operative report template without letting you know. There was supposed to be some testing and a scheduled go-live date, but that plan must have gotten lost in our communication with our vendor, and the new template dropped without anyone knowing about it. I quickly found out when all of you started sending me negative feedback. I’ll try to make sure changes are better communicated in the future.

So why did we want to change the template in the first place? One word—compliance. Drs. Maegen Wallace, chair of the Department of Surgery from 2020-2021, and Paul Esposito, surgeon-in-chief, have been keeping their eyes on operative report compliance. According to them, the organization needs to do a better job of documenting the “required elements” in our reports. This is obviously a source of potential trouble with The Joint Commission (JCAHO); incomplete documentation can also compromise patient care. By adding section headings and wild cards that would require providers to address each element before signing the report, we thought we could drive more complete documentation and increase our compliance.

We immediately received feedback about the order of the elements in the template, as well as about the necessity of each of the sections—one surgeon pointed out that JCAHO does not actually require all the elements in the template in operative reports. We based the template on an existing note template in Epic that has been around since 2012, which, in turn, was based on our medical records policy (MS059). Upon more careful research, here’s what I found regarding who requires what in an operative report (I even threw in the Centers for Medicare and Medicaid Services (CMS) for the LOLs):

ElementCMS RequirementJCAHO RequirementChildren’s Policy
Date and time of procedure  
Name(s) of surgeon(s) 
Names of assistants (if any)  
Pre-operative diagnosis  
Post-operative diagnosis 
Name of procedure performed 
Type of anesthesia administered  
Complications (if any)  
Findings 
Estimated blood loss 
Detailed description of the procedure
Tissues or specimens removed or altered
Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner  
Prosthetic devices, grafts, tissue, transplants, or devices implanted (if any)  

As Mr. Spock would say, “fascinating.”  As you can see, Children’s policy is the most rigorous of the three. In response, we are removing the Patient Name, Consent and Disposition sections of the dictation template. That’s the good news. The bad news is that also based on Children’s policy, we are adding Assistants and Complications. And there’s more. JCAHO openly states they were very careful in adding the words if any to the Estimated Blood Loss requirement. This means (their words, not mine) that if there wasn’t any blood loss, it doesn’t need to be documented. However, Children’s policy doesn’t account for this.

So, we’ll make some changes to the headings and re-order them so that the report makes a little more sense, and the wild cards are there to stay so that we can ensure dictated operative reports comply with our documentation policy. I understand your frustration, and at the same time, we are bound by what the policy writers thought was important. If you disagree with the policy, I strongly encourage you to get together with your peers, draft a revision and propose it to the Medical Executive Committee. I joke a lot in these columns, but this isn’t one of those times. We shouldn’t limit ourselves to venting about our frustrations—we should invent ways out of them.

All that said, if portions of your reports aren’t being transcribed into the right sections, let me know, and I’ll relay that feedback to our service provider.

Thanks for understanding and for all you do!

Stephen Dolter, M.D. | CMIO