结构化手术报告：一项使用听写模板改善手术报告的随机试验。

Structured operative reporting: a randomized trial using dictation templates to improve operative reporting.

作者信息

Gillman Lawrence M, Vergis Ashley, Park Jason, Minor Sam, Taylor Mark

机构信息

Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.

出版信息

Am J Surg. 2010 Jun;199(6):846-50. doi: 10.1016/j.amjsurg.2009.06.030.

DOI:10.1016/j.amjsurg.2009.06.030

PMID:20609727

Abstract

BACKGROUND

Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template.

METHODS

Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation.

RESULTS

There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02).

CONCLUSIONS

The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.

摘要

背景

很少有研究探讨口述手术报告（OR）的质量。本研究记录了引入标准化手术报告模板后住院医师口述情况的变化。

方法

20名住院医师根据手术视频口述一份手术报告。住院医师被随机分为接受手术报告模板组或无干预组。3个月后，住院医师再口述一份报告。结果测量指标为使用先前验证的工具评估的口述质量以及住院医师对口述的舒适度。

结果

通过结构化评估表（SAF）（28.6对30.0，P = 0.36）和整体质量评级量表（GQRS）（21.7对21.8，P = 0.96）测量，干预组的质量总体上没有差异。然而，低年资住院医师亚组分析显示，干预组在SAF（23.2对28.3，P = 0.02）和GQRS（17.1对20.4，P = 0.02）上均有改善。干预组的主观舒适度有所提高（P = 0.02）。