Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system
Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system
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DOI：
10.1016/j.surg.2009.09.032
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发表时间：
2009-12-01
期刊：
影响因子：
3.8
通讯作者：
Temple, Walley J.
中科院分区：
文献类型：
--
作者：
Chambers, Anthony J.;Pasieka, Janice L.;Temple, Walley J.
背景资料。甲状腺切除术的记录传统上是由外科医生口述的手术报告(DORS)执行的。开发了一个基于Web的系统，该系统生成甲状腺切除术的概要报告(.WebSMR)。本研究的目的是评估WebSMR和DOR中文献的完整性。总共对271例DORS和133例WebSMR进行了综述，包括(1)Macis评分计算的预后信息；(2)关键解剖结构，如喉返神经(RLN)和甲状旁腺；(3)非必要信息，如甲状腺中静脉(MTV)结扎和缝合。总体上，DOR记录了27%的有无侵犯，仅3%的切除完全，29%的肿瘤大小，而这些在WEBSMR中100%被记录(P<；.001)。麦吉斯的分数无法计算出来。任何DOA，而WebSMR在软件中集成了Macis计算器。尽管根据训练的不同，DORS在报告解剖结构方面有细微的差异，但DORS在报告RLN(>；95%)和甲状旁腺(>；83%)方面做得很好，而WebSMR则是100%。DOR通常包括不必要的信息；MTV(80%)和缝合(93%~98%)。在记录关键的预后和解剖学发现方面，WebSMR优于DOX5，没有必要的信息，而且它产生了有助于术后护理的更好的文件。(外科手术2009；146：1090-8。)
Background. Documentation of thyroidectomy is performed traditionally by surgeon-dictated operative reports (DORs). A Web-based system that generates a synoptic report (.WebSMR) for thyroidectomy was developed. The purpose of this study was to assess the completeness of documentation in WebSMR compared with DOR.Methods. In all, 271 DORs and 133 WebSMR were reviewed for the documentation of (1) prognostic information for the MACIS score calculation; (2) key anatomic structures such as recurrent laryngeal nerve (RLN) and parathyroid glands; and (3) nonessential information such as middle thyroid vein (MTV) ligation and sutures used for closure.Results. Overall DOR documented presence/absence of invasion in 27%, completeness of resection in only 3%, and tumor size in 29%, whereas these were recorded in 100% of WEBSMR (P < .001). The MACIS scores could not be calculated from. any DOA whereas WebSMRs have a MACIS calculator incorporated in the software. Although subtle differences were found in reporting anatomic structures depending on training, DORs were good at reporting the status of the RLNs (> 95%) and parathyroids (> 83%) compared with 100% in WebSMRs. DOR routinely included nonessential information; MTV (80%) and sutures used for closure (93% to 98%).Conclusion. Use of the WebSMRs was superior to DOX5 in documenting key prognostic and anatomic findings without nonessential information, and it produced a superior document that can aid in postoperative care. (Surgery 2009;146:1090-8.)