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[耳鼻咽喉科的结构化报告]

[Structured reporting in otorhinolaryngology].

作者信息

Ernst Benjamin Philipp

机构信息

Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.

出版信息

HNO. 2025 Mar 26. doi: 10.1007/s00106-025-01605-4.

Abstract

Structured reporting (SR) is a valuable method for optimizing diagnosis and treatment in various specialist disciplines. While conventional free-text findings are often inconsistent and difficult to compare, structured documentation enables higher quality and completeness of findings. This helps to better manage the increasing complexity and raise therapeutic standards. Studies show that SR leads to a significant improvement in the quality of findings in various areas of otorhinolaryngology. SR also increases time efficiency and inter-rater reliability and contributes to the learning effect. Furthermore, SR increases user and referring physician satisfaction, especially in interdisciplinary application. Future multicenter studies are needed to provide further insights into the practical application and scientific evaluability of SR, also in combination with artificial intelligence.

摘要

结构化报告(SR)是一种在各个专业学科中优化诊断和治疗的重要方法。传统的自由文本式检查结果往往不一致且难以比较,而结构化文档能够提高检查结果的质量和完整性。这有助于更好地应对日益增加的复杂性并提高治疗标准。研究表明,SR能显著提高耳鼻咽喉科各个领域的检查结果质量。SR还能提高时间效率和评分者间的可靠性,并有助于学习效果。此外,SR能提高用户和转诊医生的满意度,尤其是在跨学科应用中。未来需要进行多中心研究,以进一步深入了解SR的实际应用和科学可评估性,包括与人工智能相结合的情况。

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