Amanda Nikolic, Isaac Tranter-Entwistle, Andrew McCombie, Saxon Connor, Tim Eglinton
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引用次数: 0
摘要
目的准确的文件记录对外科患者护理至关重要。综合报告（SR）是基于核对表的结构化报告，是传统叙述式报告（NR）的标准化替代方案。本系统综述旨在评估在结直肠癌（CRC）手术中，SR 与 NR 相比的完整性。方法通过对 Ovid MEDLINE、Embase (Ovid)、CIHNAL Plus with Full Text (EBSCOhost) 和 Cochrane 进行系统检索，确定了评估结直肠癌手术过程中 SR 与 NR 相比完整性的前瞻性或回顾性研究。结果分析纳入了 1797 份手术报告（NR, 729; SR, 1068）。在所有报告该结果的研究中，SR 的记录完整性明显更高（P < 0.001）。次要结果的报告有限，主要集中在研究价值方面。有几项研究表明，在使用 SR 时，数据提取时间明显缩短。外科医生对 SR 的满意度很高，这些报告被视为有价值的研究和教育工具。实施的障碍包括将 SR 整合到现有的电子病历 (EMR) 中，以及外科医生对增加管理负担的担忧。外科医生认为 SR 有利于研究、质量改进和教学。本综述支持有必要开发用户友好型 SR，将其无缝集成到已有的 EMR 中，从而优化患者护理并提高 CRC 手术记录的质量。
The utility of synoptic operation reports in colorectal surgery: a systematic review
Purpose
Accurate documentation is crucial in surgical patient care. Synoptic reports (SR) are structured checklist-based reports that offer a standardised alternative to traditional narrative reports (NR). This systematic review aims to assess the completeness of SR compared to NR in colorectal cancer (CRC) surgery. Secondary outcomes include the time to completion, surgeon satisfaction, educational value, research value, and barriers to implementation.
Methods
Prospective or retrospective studies that assessed SR compared to NR in colorectal cancer surgery procedures were identified through a systematic search of Ovid MEDLINE, Embase (Ovid), CIHNAL Plus with Full Text (EBSCOhost), and Cochrane. One thousand two articles were screened, and eight studies met the inclusion criteria after full-text review of 17 papers.
Results
Analysis included 1797 operative reports (NR, 729; SR, 1068). Across studies reporting this outcome, the completeness of documentation was significantly higher in SR (P < 0.001). Reporting of secondary outcomes was limited, with a predominant focus on research value. Several studies demonstrated significantly reduced data extraction times when utilising SR. Surgeon satisfaction with SR was high, and these reports were seen as valuable tools for research and education. Barriers to implementation included integrating SR into existing electronic medical records (EMR) and surgeon concerns regarding increased administrative burden.
Conclusions
SR offer advantages in completeness, data extraction, and communication compared to NR. Surgeons perceive them as beneficial for research, quality improvement, and teaching. This review supports the necessity for development of user-friendly SR that seamlessly integrate into pre-existing EMRs, optimising patient care and enhancing the quality of CRC surgical documentation.
期刊介绍：
The International Journal of Colorectal Disease, Clinical and Molecular Gastroenterology and Surgery aims to publish novel and state-of-the-art papers which deal with the physiology and pathophysiology of diseases involving the entire gastrointestinal tract. In addition to original research articles, the following categories will be included: reviews (usually commissioned but may also be submitted), case reports, letters to the editor, and protocols on clinical studies.
The journal offers its readers an interdisciplinary forum for clinical science and molecular research related to gastrointestinal disease.
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