Fang S, Habeeb A, Gluckman P, Kanegoankar R
ENT Department,Medway Maritime Hospital,Gillingham,UK.
J Laryngol Otol. 2017 May;131(5):462-464. doi: 10.1017/S002221511700041X. Epub 2017 Mar 14.
The middle ear and mastoid are complex three-dimensional structures and therefore tympanomastoid procedures require detailed documentation. Traditional written accounts can be inaccurate and difficult to interpret.
This audit of 95 patients compares the completion of essential operative details using: an all-electronic version of a standardised proforma with a diagrammatic template, a non-electronic version with a diagrammatic template, and a traditional handwritten template.
The electronic template resulted in 81 per cent of essential operative items being recorded, compared to 78 per cent (p = 0.3) with a previous non-electronic template and 50 per cent (p = 0.0004) when using simple handwritten recording.
An electronic proforma with a diagrammatic template improves the documentation and interpretation of tympanomastoid procedures compared to traditional handwritten records.
中耳和乳突是复杂的三维结构，因此鼓室乳突手术需要详细记录。传统的书面记录可能不准确且难以解读。
本次对95例患者的审核比较了使用以下方式完成基本手术细节记录的情况：带有图表模板的标准化表格的全电子版本、带有图表模板的非电子版本以及传统手写模板。
电子模板记录了81%的基本手术项目，相比之下，之前的非电子模板为78%（p = 0.3），使用简单手写记录时为50%（p = 0.0004）。
与传统手写记录相比，带有图表模板的电子表格可改善鼓室乳突手术的记录和解读。
