Laparotomy operative note template constructed through a modified Delphi method

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• 作者：Lolonya Moore ; Ruth Churley-Strom ; Bonita Singal ; Sharon O'Leary
• 关键词：Delphi method ; laparotomy operative note
• 刊名：American Journal of Obstetrics and Gynecology
• 出版年：2009
• 出版时间：May 2009
• 年：2009
• 卷：200
• 期：5
• 页码：e16-e17
• 全文大小：134 K

文摘

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.