腹腔镜胆囊切除术和胰十二指肠切除术的概要手术报告：一项多机构试点研究，评估其完整性和外科医生的认知。

Synoptic operative reporting for laparoscopic cholecystectomy and pancreaticoduodenectomy: A multi institutional pilot study evaluating completeness and surgeon perceptions.

机构信息

Virginia Mason Medical Center, General Thoracic and Vascular Surgery, 1100 9th Avenue, Seattle, WA, 98101, USA.

Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.

出版信息

Am J Surg. 2018 Nov;216(5):935-940. doi: 10.1016/j.amjsurg.2018.06.008. Epub 2018 Jun 19.

BACKGROUND

Synoptic operative reports (SOR) are more accurate than dictated operative reports (DOR) in a few single institution experiences. We sought to examine the completeness of SOR for laparoscopic cholecystectomy (LC) and pancreaticoduodenectomy (PD) in a multi institutional pilot study.

METHODS

Six institutions participated in SOR submission via a web-based survey. One institution collected DOR and case matched historical dictated operative reports (HOR) for subset analysis. A checklist evaluated completeness of all reports. A post-survey assessed participant opinions.

RESULTS

40 PD SORs were 98.5% complete and 35 LC SORs were 99.7% complete. Single institution subset analysis respective percent complete were: 11 PD SORs 99%, DORs 70% and HORs 74% and 14 LC SORs 99.7%, DORs 76%, and HORs 75%. Post-survey results yielded 10 PD and 24 LC responses. An overwhelming majority agreed that SOR were easy to use and would prefer to use SOR compared to DOR.

CONCLUSION

SOR are more complete than both study associated DOR and HOR. The majority of surgeons indicated their preference for SOR and their willingness to use them.

背景

在一些单机构的经验中，摘要手术报告（SOR）比口述手术报告（DOR）更准确。我们旨在通过一项多机构试点研究，检查腹腔镜胆囊切除术（LC）和胰十二指肠切除术（PD）的 SOR 完整性。

方法

六家机构通过网络调查提交 SOR。一家机构收集了 DOR 和病例匹配的历史口述手术报告（HOR）进行子组分析。检查表评估了所有报告的完整性。调查后评估了参与者的意见。

结果

40 份 PD SOR 完整率为 98.5%，35 份 LC SOR 完整率为 99.7%。单机构子组分析的相应完整率分别为：11 份 PD SOR 完整率为 99%，DOR 为 70%，HOR 为 74%；14 份 LC SOR 完整率为 99.7%，DOR 为 76%，HOR 为 75%。调查后的结果产生了 10 份 PD 和 24 份 LC 的回应。绝大多数人同意 SOR 比研究相关的 DOR 和 HOR 更完整。大多数外科医生表示他们更喜欢使用 SOR 而不是 DOR。