AbstractsLaw & Legal Studies

The dictated operative note is an important and integral part of the patient record. Despite their importance little material regarding the quality of operative notes have been published. Do they accurately reflect the events that occure during an operative procedure? We wanted to examine this by reviewing the video recordings of cholecystectomies performed in a local hospital in Norway. We examined 193 consecutive elective laparoscopic cholecystectomies that had been videotaped. Perioperative events were classified and registered into different categories. The corresponding operative note was scrutinized and events registered into the same categories. The videotapes and operative notes were examined retrospectively. Ten different surgeons had dictated the operative notes. A total of 225 and 204 events were recorded from the videotapes and the operative notes respectively. In 63 cases no events were recorded, neither on videotape or in the corresponding operative note. In 27 cases the number and type of events exactly matched. This means that in 90 out of 193 cases (47%) there was concurrence between the video and operative note. There was considerable variation in the way surgeons dictated their notes. There were also differences between the different categories of events. Bleedings were reported more often in the operative note (88) compared to the videotapes (63). This was due to the fact that some bleedings were considered to be part of the procedure upon examining the videotapes and were not recorded as an event. Events with serious complications like injuries to the bile ducts and small intestine were well documented. Liver lacerations were left out in the operative report in two third of the cases, and perforation of the gallbladder and ductus cysticus were reported 52 times in the operative notes, but 61 on the videotapes. Leakage of bile was left out 12 times compared to the videos 47 cases. The operative notes we have examined included the main events, but there is room for improvement on certain details. Laparoscopic procedures are well suited for video documentation and therefore suitable for assessment of the surgical content of the operative note.