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作为甲状腺手术质量指标的综合操作报告的开发和验证:一项加拿大研究

Akie Watanabe¹, Susan Yao¹, Eitan Prisman¹

¹Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.

Annals of surgical oncology

|February 7, 2025

概括

与传统叙事报告相比,用于甲状腺手术的新标准化综合性手术报告 (SOR) 显著提高了报告的完整性和癌症特异性细节,提高了患者护理质量.

科学领域:

手术瘤学手术瘤学
医疗信息学医疗信息学
临床文档临床文档

背景情况:

对于甲状腺手术的传统叙述性手术报告往往省略了关键的术后管理数据.
这种缺陷会影响甲状腺疾病的有效管理.

研究的目的:

开发和验证甲状腺手术的全国标准化综合性手术报告 (SOR).
提高甲状腺手术手术文件的质量和完整性.

主要方法:

采用了修改后的Delphi方法,涉及外科医生调查和专家对可报告元素的排名.
一个国家咨询委员会完成了21个元素的SOR,然后由六名外科医生试点进行.
统计分析 (威尔科克森等级和,奇平方,费舍尔精确) 将SOR完整性与飞行员前叙述性操作报告 (NOR) 进行了比较.

主要成果:

一个21元标准化的SOR被开发和验证.
与NOR (65%,p < 0.001) 相比,SOR的整体完整性显著更高 (100%).
与NOR相比,SOR显著改善了关键癌症特异因素的报告,例如甲状腺外延伸和残留疾病.

结论:

实施国家标准化甲状腺手术SOR提高了文档完整性和提供必要的癌症特异性信息.
这种标准化会提高提供者的满意度,并可能对患者护理的质量产生积极影响.
在甲状腺疾病中,SOR是优化术后管理策略的宝贵工具.

关键词:

电子健康记录电子健康记录混合方法研究研究混合方法研究.叙述性行动报告叙述性行动报告标准化的报告报告.综合性行动报告综合性行动报告甲状腺手术甲状腺手术

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