Prospective, Blinded Evaluation of Accuracy of Operative Reports Dictated by Surgical Residents

Novitsky, Yuri W.; Sing, Ronald F.; Kercher, Kent W.; Griffo, Martha L.; Matthews, Brent D.; Heniford, B. Todd
August 2005
American Surgeon;Aug2005, Vol. 71 Issue 8, p627
Academic Journal
Incomplete or inaccurate operative notes result in delayed, reduced, or denied reimbursement. Deficient reports may be more common when dictated by the surgical residents. We performed a blinded study to assess the accuracy of residents' dictations and their effect on the appropriate level of coding for reimbursement. A prospective, blinded study was performed comparing operative reports dictated by senior surgical residents (postgraduate years 3, 4, and 5) to reports dictated by attending surgeons. All residents had previously undergone group instruction on the importance and structure of operative notes. The trainees were blinded to the fact that the attending surgeons were dictating the operative reports on a separate dictation system. The dictations were analyzed by faculty reimbursement billing personnel for accuracy and completeness. Fifty operative reports of general surgical procedures dictated by both surgical residents and attending physicians were reviewed. A total of 97 CPT codes were used to report services rendered. Residents' dictations resulted in incorrect coding in 14 cases (28% error rate). The types of inaccuracies were a completely missed procedure (4) and insufficient documentation for an appropriate CPT code and/or modifier (10). All deficiencies occurred in complex, multicode, and/or laparoscopic cases. Sixty-seven per cent of late dictations were incomplete. The financial analysis revealed that deficiencies in resident dictations would have reduced the reimbursement by $18,200 (9.7%). For cases with deficient dictations, 29.5 per cent of charges would have been missed, delayed, or denied if the resident-dictated note was used to justify charges. Operative reports dictated by surgical residents are often incomplete or inaccurate, likely leading to reduced or delayed reimbursement. Dictations of complex, multicode, or laparoscopic surgeries, especially if delayed beyond 24 hours, are likely to contain significant deficiencies that affect billing. Attending surgeons may be better equipped to dictate complex cases. Formal housestaff education, mentorship by the attending faculty, and ongoing quality control may be paramount to minimize documentation errors to ensure appropriate coding for the services rendered.


Related Articles

  • The Alternative to the Saphenous Vein as an Arterial Graft. Limet, Raymond R. // Vascular Surgery;Jul/Aug1984, Vol. 18 Issue 4, p201 

    If God created the saphenous vein for the sake of vascular surgeons, He neglected to create all men equal in respect to the presence of saphenous veins for needed revascularizations. Therefore, the burden of finding alternatives to saphenous veins reverts to the humble ingenuity of man.

  • Research Projects Shortage of General Surgeons by 2010.  // O&P Business News;2/1/2009, Vol. 18 Issue 3, p46 

    The article focuses on a study which found that there will be a shortage of general surgeons in the U.S. hospitals in 2010 to treat the critically injured or chronically ill people. The study reveals that the shortage may cause disease progresses and that can create more serious problems in...

  • The IXth Biennial Meeting of the Mediterranean Society of Coloproctology, May 22-23, 2014. Tsoulfas, G.; Pramateftakis, M. // Techniques in Coloproctology;Nov2014, Vol. 18 Issue 11, p1141 

    The article reports that the IXth Biennial Meeting of the Mediterranean Society of Coloproctology (MSCP) was held in Sottomarina di Chioggia in Italy from on May 22-23, 2014. In the meeting, surgeons from the Mediterranean region, experts in the field of coloproctology attended the conference in...

  • UK surgeons' fees are the highest in the world. Cooper, Richard // British Journal of Perioperative Nursing;Mar2004, Vol. 14 Issue 3, p92 

    Details the results of a survey showing that surgeons in Great Britain receive the highest fees for private operations. Higher costs passed on to patients.

  • surgeon. Peters, Michael // BMA A-Z Family Medical Encyclopedia;2004, p722 

    A definition of the term "surgeon" is presented. It refers to a medical practitioner who is qualified to carry out surgery. However, this definition does not cover dental surgeons who are not medically qualified to perform surgery.

  • Qualities of a good surgeon. Choudhary, R. K. // BMJ: British Medical Journal (International Edition);8/7/2004, Vol. 329 Issue 7461, p314 

    Presents a treatise written by Sustrata, recognized as the father of Indian surgery, regarding the qualities of a good surgeon.

  • Consoling Mrs Byrne. Moore, S. Breanndan // JAMA: Journal of the American Medical Association;10/24/90-10/31/90, Vol. 264 Issue 16, p2121 

    Presents an article on experiences as a surgeon. Professional background; Details on the case of a tumor patient; Approach used in telling the patient about the condition.

  • General Surgery. Kuchna, John; de Gennaro, Renee // Pharmaceutical Representative;May2011, Vol. 41 Issue 5, p28 

    The article focuses on the work of a general surgeon, a physician trained and educated in the diagnosis and preoperative, operative and postoperative management of patient care. It mentions the education and training required for a general surgeon in the U.S., including the five-year residency...

  • The Role of the College for Practicing General Surgeons. Russell, Thomas R. // American Surgeon;Feb2006, Vol. 72 Issue 2, p107 

    The article discusses the role of the American College of Surgeons (ACS) for practicing general surgeons. It is emphasized that the ACS strives to serve all surgeons and members of the operating team will remaining steadfast in its commitment to general surgery. It is also added that the ACS is...


Read the Article


Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics