Harvey A, Zhang H, Nixon J, Brown C J
Division of General Surgery, Peter Lougheed Center, Calgary, Canada.
Surgery. 2007 Jun;141(6):708-14. doi: 10.1016/j.surg.2007.01.022.
The purpose of this study was to compare the completeness and reproducibility of data extracted from a standardized operative report (SOR) with the non-standardized operative report (NSOR).
Between July and December 2003, operative data were collected from all laparoscopic cholecystectomy procedures performed at the Peter Lougheed Centre Hospital. A standardized format for dictating laparoscopic cholecystectomy operative reports was introduced on October 1, 2003. Non-standardized operative reports dictated in the first 3 months of the study period were compared with SORs dictated in the final 3 months. Two physicians independently extracted data from each operative report into a surgical database.
During the study period, 221 cholecystectomy reports were analyzed (119 SOR and 102 NSOR). Completeness of data extraction for identifying variables (eg, patient name, age, and date of procedure) was similar in the 2 types of reports. However, most other operative and perioperative details were more completely reported in the SOR (95% to 100%) when compared to the NSOR (14% to 100% complete). Furthermore, interobserver agreement between 2 independent data extractors was better for the SOR than the NSOR (0.9972 vs 0.9809, P < .0001).
Standardized operative reports result in more complete and reliably interpretable operative data compared with NSORs.
本研究的目的是比较从标准化手术报告（SOR）和非标准化手术报告（NSOR）中提取的数据的完整性和可重复性。
2003年7月至12月期间，收集了彼得·洛希德中心医院所有腹腔镜胆囊切除术的手术数据。2003年10月1日引入了一种用于口述腹腔镜胆囊切除术手术报告的标准化格式。将研究期前3个月口述的非标准化手术报告与最后3个月口述的SOR进行比较。两名医生独立地将每份手术报告中的数据提取到一个手术数据库中。
在研究期间，分析了221份胆囊切除术报告（119份SOR和102份NSOR）。在两种类型的报告中，识别变量（如患者姓名、年龄和手术日期）的数据提取完整性相似。然而，与NSOR（完成率为14%至100%）相比，大多数其他手术和围手术期细节在SOR中报告得更完整（95%至100%）。此外，两名独立数据提取者之间的观察者间一致性在SOR中比在NSOR中更好（0.9972对0.9809，P <.0001）。
与NSOR相比，标准化手术报告能产生更完整且可可靠解释的手术数据。
