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<p>Even today, surgical reports are usually dictated in a free text form (FTR), leading to a wide range in report-quality. This study investigated the use of a fully structured panendoscopy report (SR) compared to FTRs. 64 panendoscopies were performed by three experienced head and neck surgeons. The surgical reports were created as both FTRs and SRs, which were examined regarding time to completion and content using a multilevel regression analysis. User satisfaction was evaluated using a questionnaire. There was no significant difference in time to complete the SRs compared to FTRs. The completeness ratings of SRs were significantly higher than for FTRs (81% vs. 66%, <i>p</i> &lt; 0.001), leading to increased report quality. Overall user satisfaction was higher for SRs than for conventional FTRs (VAS 8.1 vs. 3.5, <i>p</i> &lt; 0.001). The SRs proved to be fast to complete and more comprehensive with a higher completeness of content. Participating surgeons indicated that they preferred SRs over FTRs because of their advantages in terms of structure, guidance for inexperienced residents and non-native speakers. The data stratification also enables secondary data use to further develop deep learning algorithms in patient care and research.</p>

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Structured panendoscopy reports improve report completeness and documentation time

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年11月25日

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  • Friederike Bärhold,
  • Stephan Matthias Wolpert,
  • Benjamin Philipp Ernst,
  • Georg Long Fei Potthast,
  • Thomas Breuer,
  • Sven Becker,
  • Lotte Pummerer,
  • Martin Holderried

摘要

Even today, surgical reports are usually dictated in a free text form (FTR), leading to a wide range in report-quality. This study investigated the use of a fully structured panendoscopy report (SR) compared to FTRs. 64 panendoscopies were performed by three experienced head and neck surgeons. The surgical reports were created as both FTRs and SRs, which were examined regarding time to completion and content using a multilevel regression analysis. User satisfaction was evaluated using a questionnaire. There was no significant difference in time to complete the SRs compared to FTRs. The completeness ratings of SRs were significantly higher than for FTRs (81% vs. 66%, p < 0.001), leading to increased report quality. Overall user satisfaction was higher for SRs than for conventional FTRs (VAS 8.1 vs. 3.5, p < 0.001). The SRs proved to be fast to complete and more comprehensive with a higher completeness of content. Participating surgeons indicated that they preferred SRs over FTRs because of their advantages in terms of structure, guidance for inexperienced residents and non-native speakers. The data stratification also enables secondary data use to further develop deep learning algorithms in patient care and research.