Đánh giá tính đầy đủ, chính xác, lợi ích thời gian và dữ liệu của tường trình phẫu thuật điện tử

Surgeons often building operative reports by typing free text and/or handwritten templates. These can be incomplete and time-consuming to complete. Objective: To evaluate the completeness, accuracy, timely and data storage between electronic operative reports. Subjects and Methods: The research subjects included 33,088 surgical reports of 7 specialties: Chiropractic, Cardiothoracic, Vascular, Gastrointestinal, Nephrological and Urological, Orthopedic Trauma, and Plastic Surgery from January 2023 to December 2023 at Viet Duc Hospital, Hanoi Medical University Hospital, Ho Chi Minh City Medicine and Pharmacy University. Results: Electronic reports improved compliance with national and international standards for surgical reporting, limiting subjective errors from typing and improving overall accuracy. The reporting speed of the electronic group is shortened by 3.5 times; which saves 14 597.7 working hours and stores 1.3 billion data points in comparison with the the current method. Conclusion: Electronic surgical reports are an effective support tool for surgeons to significantly improve the completeness and accuracy of surgical reports, minimize reporting time, and bring huge data storage to clinical, research and training.