综述报告:在脏外科手术中结构化标准化手术报告的利益
Sophian Hmila1, Frédéric Panthier2, Charles Dariane1
1Paris Cité University, Department of Urology, AP-HP, Georges-Pompidou European Hospital, 75015 Paris, France.
The French journal of urology
|October 26, 2024
概括
使用FileMaker Pro® (FMP) 模板的Synoptic操作报告 (SOR) 与叙事操作报告 (NOR) 相比,提高了数据的完整性和速度. 虽然最初的创建时间更长,但FMP提高了泌尿病程序中的数据记录效率.
科学领域:
- 泌尿器科 泌尿器科 泌尿器科 泌尿器科
- 医疗信息学 医疗信息学
- 手术报告 医疗报告
背景情况:
- 综述性工作报告 (SOR) 提供了优势,但缺乏广泛采用.
- 当前叙事操作报告 (NOR) 可能在数据完整性和效率方面存在局限性.
- 评估像SOR的FileMaker Pro® (FMP) 这样的标准化模板对于改善外科手术文档至关重要.
研究的目的:
- 为了比较综述性操作报告 (SOR) 模板 (FMP) 与传统叙述性操作报告 (NOR) 模板的性能.
- 评估数据的完整性,写作时间,写作速度以及与每个模板相关的学习曲线.
- 为了确定基于FMP的SOR在泌尿外科部门设置中的效率.
主要方法:
- 这是一项长达11周的前性病例控制研究,涉及118项切手术手术报告.
- 基于FMP的SOR与基于DXCare® (DXC) 的NOR的比较,重点是完成的数据,完成率和时间指标.
- 分析写作时间,写作速度 (数据/分钟),以及创建SOR的学习曲线.
主要成果:
- 基于FMP的SOR显示完成数据的数量 (113对59) 和完整率 (95.1%对85.5%) 显著增加.
- 虽然FMP的初始创建时间较长 (9.07分钟比7.66分钟),但它生成数据库和报告总体上更快 (9.07分钟比12.9分钟).
- 使用FMP数据填写速度大大提高 (12.9数据/分钟与9.2数据/分钟相比),随着时间的推移观察到逐步改善.
结论:
- 使用FileMaker Pro® (FMP) 的Synoptic操作报告 (SOR) 模板在泌尿器科程序的数据记录中表现出卓越的效率.
- 尽管最初的创建时间更长,但基于FMP的SOR总体上导致了更完整和更快的数据捕获.
- 基于专家建议,建议优化模板以进一步提高可用性和速度.
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