Operative reports: form and function.

HYPOTHESIS: Little is known about how closely operative reports reflect what was actually performed during an operation, nor has the construction of operative reports been adequately studied with the aims of clarifying the objectives of those reports and improving their efficacy. We hypothesized that if more attention is paid to the objectives of operative reports, their content will more predictably contain the most relevant information, which might channel thinking in beneficial directions during performance of the operation.
DESIGN: Multivariate analysis of 250 laparoscopic cholecystectomy operative reports (125 uncomplicated and 125 with bile duct injury).
SETTING: Academic research. PARTICIPANTS: University (105 cases) and community (145 cases) hospitals. MAIN OUTCOME MEASURES: Variations in content and design of operative reports. Cognitive task analysis of laparoscopic cholecystectomy was conducted, and a model operative report was generated and compared with the actual operative reports.
RESULTS: Descriptions of key elements in adequate dissection of the Calot triangle were present in 24.8% and 0.0% of operative reports from uncomplicated and bile duct injury cases, respectively. Thorough dissection of the Calot triangle, identification of the cystic duct-infundibulum junction, and lateral retraction of the infundibulum correlated with uncomplicated cases, while irregular cues (eg, perceived anatomic or other deviations) correlated with bile duct injury cases.
CONCLUSIONS: Current practice generates operative reports that vary widely in content and too often omit important elements. This research suggests that the construction of operative reports should be constrained such that the reports routinely include the fundamental goals of the operation and what was performed to meet them. Cognitive task analysis is based on the ways the mind controls the performance of tasks; it is an excellent method for determining the extra content needed in operative reports. The resulting designs should also serve as mental guidelines to facilitate learning and to enhance the safety of the operation.