甲状腺切除术的视频文档以及对手术笔记的评估
Mazin Merdad1, Hoda Alsayid1, Shouq Alsharif2
1Otolaryngology - Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU.
Cureus
|August 13, 2024
概括
与传统的书面记录相比,视频记录显著提高了甲状腺切除术手术笔记的完整性. 这种方法提高了患者护理,研究和医疗法律目的的准确性.
科学领域:
- 手术文档 手术文档
- 医疗信息学 医疗信息学
- 提高医疗保健的质量 改善医疗保健的质量
背景情况:
- 准确的外科手术笔记对于术后护理,研究和医学法律文件至关重要.
- 现有研究强调了传统操作说明中的缺陷和不准确性.
- 正在积极探索改善外科文档客观性的方法.
研究的目的:
- 评估甲状腺切除术的完整性 在第三级护理中心的手术笔记.
- 通过将视频文件与书面操作笔记进行比较来评估视频文件的充分性.
主要方法:
- 对385项甲状腺切除术手术笔记 (2010-2020年) 的回顾性审查.
- 书面笔记与15次甲状腺切除术的录像相比较.
- 基于预定义的项目清单的完整性评分.
- 使用独立样本 t 试验和单向 ANOVA 的统计分析.
主要成果:
- 追溯审查显示,书面甲状腺切除术笔记的平均完整性得分为54.47%.
- 与书面笔记相比 (47.53%) (p <0.001),视频记录的操作记录的平均完整度得分 (83.86%) 显著高于书面笔记 (47.53%) (p <0.001).
结论:
- 视频文档在甲状腺切除术手术笔记的完整性和准确性方面提供了实质性的改进.
- 视频录制是外科教育,技能培训和研究的宝贵工具.
- 实施视频记录可以提高外科记录的整体质量.
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