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手术记录的质量:简单文字处理软件能有所帮助吗?

The quality of operation notes: can simple word processors help?

作者信息

O'Bichere A, Sellu D

机构信息

Department of Surgery, Ealing Hospital NHS Trust, Southall, Middlesex.

出版信息

Ann R Coll Surg Engl. 1997 Sep;79(5 Suppl):204-8; discussion 209.

PMID:9496162
Abstract

In a retrospective study the quality of operation notes on specifically designed proformas was compared to those produced by word processors and predesigned templates and notes in patients undergoing operations for colorectal cancer. The operations in the two groups were similar. Computer notes scored higher on all criteria, were all legible and took the same time to generate. The results were given to staff in an attempt to improve the quality of future notes. Prospective comparison demonstrated that the quality of computer notes improved even further, while that of manual forms did not change. Word processor computer notes are easy to set up, amend and produce but staff should be trained in the use of personal computers and machines must be readily available in operating theatres. Word processor databases will, in addition, enable the data collected to be analysed automatically to yield information for audit and research.

摘要

在一项回顾性研究中,将专门设计的表格上的手术记录质量与文字处理器生成的记录、预先设计的模板记录以及接受结直肠癌手术患者的记录进行了比较。两组患者的手术情况相似。电脑记录在所有标准上得分更高,全部清晰可读,且生成时间相同。研究结果反馈给了工作人员,以期提高未来记录的质量。前瞻性比较表明,电脑记录的质量进一步提高,而手工表格记录的质量没有变化。文字处理器电脑记录易于设置、修改和生成,但工作人员应接受个人电脑使用培训,且手术室必须随时配备机器。此外,文字处理器数据库将使收集到的数据能够自动分析,以产生用于审计和研究的信息。

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