睡眠医学中的结构化报告
Katharina Bahr-Hamm1, Haralampos Gouveris1, Barbara Leggewie2
1Department of Otorhinolarynoglogy, University Medical Center Mainz, 55131 Mainz, Germany.
Diagnostics (Basel, Switzerland)
|May 14, 2025
概括
与自由文本报告 (FTR) 相比,结构化报告 (SRs) 显著提高了阻塞性睡眠呼吸暂停 (OSA) 睡眠医学咨询的质量和效率. SRs更全面,完成速度更快,临床医生更喜欢.
科学领域:
- 睡眠医学 睡眠医学
- 耳鼻喉科 耳鼻喉科 耳鼻喉科
- 医疗报告 医疗报告
背景情况:
- 睡眠学发现通常以变量自由文本报告 (FTR) 的形式记录.
- 睡眠医学中的报告质量因检查员的专业知识和专业而异.
- 需要标准化的报告,以实现一致的,高质量的患者评估.
研究的目的:
- 为了比较自由文本报告 (FTR) 与结构化报告 (SR) 在耳鼻喉科对阻塞性睡眠呼吸暂停 (OSA) 评估的质量.
- 评估FTR和SR的完整性,时间效率和用户满意度.
- 确定结构化报告对睡眠医学临床实践的影响.
主要方法:
- 对50名疑似OSA患者的FTR和SR进行比较.
- 为SRs开发一个标准化的基于Web的模板.
- 通过问卷评估报告的完整性,完成时间和用户满意度.
主要成果:
- 在SR中,完整度得分明显更高 (88%与54.2%,p < 0.001).
- SRs需要显著减少完成时间 (10.2分钟与16.8分钟相比,p < 0.001).
- 用户满意度在SR中显著更高 (VAS 8.3与2.2相比,p < 0.001).
结论:
- 结构化报告 (SR) 在OSA评估中比FTR更全面,更有效.
- SRs提高了检查员的满意度,并支持睡眠医学中的学习.
- 建议进行标准化的结构化报告,以改善睡眠学文档.
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