Strukturierte Befunderhebung in der Hals-Nasen-Ohren-Heilkunde
摘要
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.