Journal of the American College of Surgeons
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Our objectives are to describe the contents of cardiovascular surgical operative notes and to develop and test a standards-based structured electronic operative note that might be used for secondary purposes. ⋯ Freeform dictation of cardiovascular notes varied by individual surgeon style and case complexity. Up to 25% of the operative note was dedicated to judgment/opinion, which would be difficult to recreate in a structured data-entry format. An electronic system for entering procedural details can improve efficiency for secondary purposes of data collection but must be carefully implemented to avoid loss of important information.