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睡眠医学中的结构化报告

Structured Reporting in Sleep Medicine.

作者信息

Bahr-Hamm Katharina, Gouveris Haralampos, Leggewie Barbara, Becker Sven, Bärhold Friederike, Ernst Benjamin Philipp

机构信息

Department of Otorhinolarynoglogy, University Medical Center Mainz, 55131 Mainz, Germany.

Department of Otorhinolaryngology, University Hospital Bonn, 53127 Bonn, Germany.

出版信息

Diagnostics (Basel). 2025 Apr 28;15(9):1117. doi: 10.3390/diagnostics15091117.

Abstract

: Somnological findings are often written as free texts, supported by questionnaires. The quality and structure of free-text reports (FTRs) vary between examiners and specialties, depending on the individual level of expertise and experience in sleep medicine. This study aimed to compare the quality of free-text reports (FTRs) and structured reports (SRs) from somnological consultations in otolaryngology for patients assessed for obstructive sleep apnea (OSA). : This study compared free-text reports (FTRs) and structured reports (SRs) from 50 patients with suspected OSA, including medical history, clinical examination findings, and medical letters, all prepared by six examiners with similar experience levels. A web-based approach was used to develop a standardized template for structured somnological reporting. The completeness and time required for both FTRs and SRs were evaluated, and a questionnaire was administered to assess user satisfaction with each reporting method. : The completeness scores of SRs were significantly higher than those of FTRs (88% vs. 54.2%, < 0.001). The mean time to complete an SR was significantly shorter than that for FTRs (10.2 vs. 16.8 min, < 0.001). SRs had significantly higher user satisfaction compared to FTRs (VAS 8.3 vs. 2.2, < 0.001). : Compared to FTRs, SRs for OSA patients are more comprehensive and faster. The use of SR is more satisfactory for examiners and supports the learning effect.

摘要

睡眠学研究结果通常以自由文本形式撰写,并辅以问卷。自由文本报告(FTRs)的质量和结构因检查人员和专业不同而有所差异,这取决于睡眠医学方面的个人专业水平和经验。本研究旨在比较耳鼻喉科睡眠学咨询中针对阻塞性睡眠呼吸暂停(OSA)患者的自由文本报告(FTRs)和结构化报告(SRs)的质量。

本研究比较了50例疑似OSA患者的自由文本报告(FTRs)和结构化报告(SRs),包括病史、临床检查结果和医疗信函,所有这些均由六位经验水平相似的检查人员编写。采用基于网络的方法开发了结构化睡眠学报告的标准化模板。评估了FTRs和SRs的完整性和所需时间,并发放了问卷以评估用户对每种报告方法的满意度。

SRs的完整性得分显著高于FTRs(88%对54.2%,<0.001)。完成一份SR的平均时间显著短于FTRs(10.2分钟对16.8分钟,<0.001)。与FTRs相比,SRs的用户满意度显著更高(视觉模拟评分8.3对2.2,<0.001)。

与FTRs相比,OSA患者的SRs更全面、速度更快。SR的使用对检查人员更令人满意,并支持学习效果。

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