Use of a computerized arthroplasty registry to generate operative reports decreases transcription errors.

Abstract

Despite the clear importance of the operative report in the electronic medical record, few studies have addressed the quality. We prospectively evaluated 300 consecutive patients undergoing primary total joint arthroplasties for operative report errors utilizing three different forms of documentation (standard dictation vs. templated dictation vs. a computer registry database generated operative report). The three types of reports were evaluated for errors which were classified as either major or minor. There were significantly more total errors in the standard dictation group compared to both the computer registry database generated (p<0.001) and the templated operative reports (p<0.001). Major errors were significantly reduced in the database generated reports compared to the templated (p<0.001) and standard dictation groups (p<0.001). There were significantly more minor errors in the standard dictation group (p<0.001) compared to the other two groups. No statistically significant differences in major errors were noted when comparing standard vs. templated operative reports. There was no difference in minor or total errors between the database generated and templated operative reports. The use of a computer registry database generated operative report resulted in fewer major errors versus a templated or standard dictated operative report. Further research is warranted in this area to validate these findings across subspecialties and institutions.