在结直肠外科手术中synoptic手术报告的实用性:一个系统的审查
Amanda Nikolic1,2, Isaac Tranter-Entwistle3,4, Andrew McCombie4
1Te Whatu Ora, Waitaha, Christchurch, New Zealand. Amanda.Nikolic@cdhb.health.nz.
International journal of colorectal disease
|April 30, 2024
概括
综合报告 (SR) 与叙事报告 (NR) 相比,显著提高了结直肠癌外科手术文档的完整性. 外科医生发现SR对研究和教育有价值,尽管EMR集成是一个挑战.
科学领域:
- 医疗信息学 医疗信息学
- 手术瘤学手术瘤学
- 医疗保健服务研究 医疗服务研究
背景情况:
- 准确的外科手术文档对于患者护理至关重要.
- 传统的叙事报告 (NR) 缺乏标准化.
- 综合报告 (SR) 提供了一个结构化,基于检查清单的替代方案.
研究的目的:
- 在结直肠癌 (CRC) 手术中,系统地审查和比较综合报告 (SR) 与叙事报告 (NR) 的完整性.
- 评估二次结果,包括完成时间,外科医生满意度和教育/研究价值.
主要方法:
- 在多个数据库 (MEDLINE,Embase,CINAHL,Cochrane) 中进行系统的文献搜索.
- 包括前性和后性研究,比较CRC手术中的SR和NR.
- 分析了来自8项包括研究的1797份作战报告.
主要成果:
- 综合报告显示,文档完整性明显高于叙事报告 (P < 0.001).
- SR导致数据提取时间缩短,外科医生满意度高.
- 障碍包括EMR集成和外科医生感知到的行政负担.
结论:
- 与CRC手术中的叙事报告相比,综合报告提供了更高的完整性,数据提取效率和通信.
- 人们认为SR对研究,质量改进和教学有价值.
- 建议将用户友好的SR集成到EMR中,以优化CRC手术文档和患者护理.
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