结构化泛镜报告提高了报告的完整性和文档的时间
Friederike Bärhold1, Stephan Matthias Wolpert1, Benjamin Philipp Ernst2
1Department of Otorhinolaryngology - Head & Neck Surgery, University Hospital Tübingen, Tübingen, Germany.
Scientific reports
|November 25, 2025
概括
与自由文本报告 (FTR) 相比,结构化外科报告 (SRs) 提高了头部和部泛内镜文档质量和用户满意度. 在不增加完成时间的情况下,SRs提供了更高的完整性.
科学领域:
- 耳鼻喉科 耳鼻喉科 耳鼻喉科
- 外科信息学外科信息学
- 医疗文件 医疗文件
背景情况:
- 手术文档中的自由文本报告 (FTR) 通常会导致质量变化.
- 泛内镜报告经常使用FTRs进行指令,这给一致性和数据分析带来了挑战.
研究的目的:
- 为了比较完全结构化的泛内镜报告 (SRs) 与传统的FTRs的质量,完整性和用户满意度.
- 评估结构化报告在头部和部手术中的效率和好处.
主要方法:
- 一项由3名头手术医生进行的64次全内镜的比较研究.
- 手术报告以FTR和SR两种格式生成.
- 多级回归分析评估了报告的内容和完成时间;调查了用户的满意度.
主要成果:
- 结构化报告 (SRs) 的完整性明显高 (81%对66%,p < 0.001) 比FTRs.
- 在SR和FTR之间没有观察到完成时间的显著差异.
- 用户满意度显著高于SRs (VAS 8.1与3.5,p <0.001).用户满意度显著高于SRs (VAS 8.1与3.5,p <0.001).用户满意度显著高于SRs (VAS 8.1与3.5,p <0.001).用户满意度显著高于SRs (VAS 8.1与3.5,p <0.001).
结论:
- 结构化的泛内镜报告提高了文档完整性和用户满意度,而不会影响效率.
- SRs提供结构优势,帮助缺乏经验的外科医生和非母语使用者.
- 结构化数据有助于在患者护理和研究中开发深度学习算法的二次使用.
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