Digital documentation of the physical examination: moving the clinical breast exam to the electronic medical record
Digital documentation of the physical examination: moving the clinical breast exam to the electronic medical record
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DOI：
10.1016/j.amjsurg.2006.06.006
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发表时间：
2006-10-01
影响因子：
3
通讯作者：
Kaufman, Lauren B.
中科院分区：
文献类型：
--
作者：
Kaufman, Cary S.;Jacobson, Leslie;Kaufman, Lauren B.
背景：临床乳腺检查（CBE）的文件包括简单的手绘和简笔画，没有一个共同的词汇。需要一种能够以数字格式准确地描绘CBE，同时是客观的、可随时间再现的并且可用于电子医疗记录的设备。这种新的设备被称为触诊成像（PI）。方法：我们检查了110例乳腺肿块使用PI投诉。这个笔记本电脑大小的设备可以以视频和静止格式实时显示可触摸区域。大小，硬度，形状，均匀性，和质量的位置可以从images.Results：那些与真实的质量，PI确定的质量在94%，而物理检查确定86%。使用PI的乳腺癌阳性预测值（PPV）为94%，体格检查为78%。初级保健医生的一项调查显示，列入PI记录在咨询说明暗示的能力，经验和技能的surgeon.Conclusions：PI记录CBE及时，高效，准确的方式。可重复的记录允许多个检查员在不同时间进行客观审查。继续开展工作将优化考试方法。(c)2006 Excerpta Medica Inc. All rights reserved.
Background: Documentation of the clinical breast examination (CBE) has consisted of simple hand-drawings and stick figures without a common lexicon. There is a need for a device that can accurately depict the CBE in digital format while being objective, reproducible over time, and useable in the electronic medical record. This new device is called palpation imaging (PI).Methods: We examined 110 patients with a complaint of a breast mass using PI. This laptop-sized device creates a real-time digital display of the palpable area in both video and still formats. The size, hardness, shape, homogeneity, and mass location may be extracted from the image.Results: Of those with a true mass, PI identified the mass in 94% while physical examination identified 86%. The positive predictive value (PPV) for breast cancer using PI was 94% and 78% for physical examination. A survey of primary care physicians revealed the inclusion of the PI record in a consultation note implied competence, experience, and skill by the surgeon.Conclusions: PI documented the CBE in a timely, efficient, and accurate manner. A reproducible record allows objective review by multiple examiners at varied times. Continued work will optimize examination methods. (c) 2006 Excerpta Medica Inc. All rights reserved.