Table 2

Note and procedures process characteristics, n = 74

CharacteristicNo. present (%)*
Administrative
 Chart no.74 (100)
 Date of surgery74 (100)
 Date of dictation74 (100)
 Dictating physician73 (99)
 Median (range)4 (3–4)
Procedure
 Surgeon73 (99)
 Incision73 (99)
 Preoperative diagnosis68 (92)
 Assistants67 (91)
 Procedure performed66 (89)
 Postoperative diagnosis57 (77)
 Proposed procedure51 (69)
 Position49 (66)
 Median (range)7 (3–8)
Clinical information
 Indication for surgery listed71 (96)
 Comorbidities listed60 (81)
 Median (range)2 (0–2)
Process
 Patient disposition66 (89)
 Sponge/instrument count reported45 (61)
 Consent obtained43 (58)
 Specimen disposition24 (32)
 Preoperative antibiotics22 (30)
 DVT prophylaxis19 (26)
 Urgency of surgery13 (18)
 Time out performed11 (15)
 ASA status0
 Median (range)3 (0–7)
  • ASA = American Society of Anesthesiologists; DVT = deep vein thrombosis.

  • * Unless otherwise indicated.