Merry Chris, Goodall-Wilson Darrin, Guest Glenn, Papas Chris, Selvidge Jannie, Watters David A K
Department of Surgery, University of Melbourne and Barwon Health, Geelong Hospital, Melbourne, Victoria, Australia.
ANZ J Surg. 2006 Mar;76(3):185-9. doi: 10.1111/j.1445-2197.2006.03676.x.
The objective of this study was to design a trainee logbook suitable for both surgical training and surgical audit. The fields of the logbook should conform to both the current requirements for surgical trainee logbooks and the minimum and recommended datasets for surgical audit. The database should be able to share information with other databases including hospital information systems. The current logbook requirements do not include much outcome data. Therefore, keeping the logbook does not train the young surgeon to collect all the information necessary for surgical audit, particularly the recently promoted minimum (12 fields) and recommended (22 fields) datasets.
An electronic logbook was developed as part of the hospital's clinical information system (CORDis). Patient identifier information was available in the system and did not need to be re-entered (e.g. name, number, date of birth and sex). The trainee only input the necessary fields for his/her logbook and was able to derive information already available from CORDis on complications, outcome and final diagnosis of the patient.
Thirteen of 16 trainees used the program over a period of 2.5 years, and more than 4600 operative procedures were recorded. Information on outcome and complications was included in the logbook, regardless of who in the team entered the data. This also facilitated surgical audit presentations. Logbook reports for the Advanced Training Board were produced with the click of a mouse rather than by spending a whole weekend counting items in the operation register at the end of a 6-month rotation. This system could be used at different hospitals or the data can be exported to another database including databases on a hand-held device.
The logbook contains all the data for reporting to the Specialty Training Board and Surgical Audit. Duplication of data entry was reduced, and presentation of unit/trainee surgical audits was facilitated. The data can be exchanged with other common databases when the trainee rotates out of Geelong.
本研究的目的是设计一种适用于外科培训和外科审计的实习医生日志。日志的字段应符合当前外科实习医生日志的要求以及外科审计的最低和推荐数据集。该数据库应能够与包括医院信息系统在内的其他数据库共享信息。当前的日志要求并未包含太多结果数据。因此，记录日志并不能训练年轻外科医生收集外科审计所需的所有信息，尤其是最近推行的最低（12个字段）和推荐（22个字段）数据集。
开发了一个电子日志作为医院临床信息系统（CORDis）的一部分。系统中已有患者标识信息，无需重新输入（如姓名、编号、出生日期和性别）。实习医生只需输入其日志所需的必要字段，并能够从CORDis中获取有关患者并发症、结果和最终诊断的已有信息。
16名实习医生中有13名在2.5年的时间里使用了该程序，记录了超过4600例手术过程。无论团队中谁输入数据，日志中都包含了结果和并发症信息。这也便于进行外科审计报告。只需点击鼠标就能生成高级培训委员会的日志报告，而无需在6个月轮训结束时花费整个周末在手术登记册中清点项目。该系统可在不同医院使用，或者数据可导出到另一个数据库，包括手持设备上的数据库。
该日志包含了向专科培训委员会和外科审计报告所需的所有数据。减少了数据录入的重复工作，便于进行科室/实习医生的外科审计报告。当实习医生转出吉朗时，数据可与其他通用数据库交换。
