Cesarean Operative Reports: We Can Do Better!

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.