The role of structured reports in diagnostics and therapy planning of sleep-related respiratory disorders

Introduction In the diagnosis of sleep-related respiratory disorders, a detailed anamnesis and assessment of the anatomical characteristics of the head and neck region are indispensable for initiating adequate diagnostic procedures and therapy. In the past, sleep-specific anamnesis and findings have proved to be extremely time-consuming in their implementation and documentation. The use of a structured report (SR) of diagnostic and therapeutic measures demonstrably increases the quality of findings and time efficiency in many areas. The aim of this study is to compare the quality of findings of free text findings (FTR) and SR with regard to completeness, efficiency and user satisfaction.

Materials and Methods: SR was used in sleep medicine patients for the collection of anamnesis, clinical and technical examination findings as well as for the preparation of corresponding physician letters by advanced assistant physicians. Corresponding FTR and SR were subsequently evaluated with regard to quality of findings and time expenditure. In addition, user satisfaction was evaluated by means of a questionnaire with a visual analogue scale (VAS).

Results The SR showed a significantly higher completeness of findings in all partial aspects (92.8 % vs. 52.6 %, p < 0.001). The time required for SR was significantly less than for FTR (10.2 min vs. 16.8 min, p < 0.001) and the user satisfaction was significantly higher (VAS 8.3 vs. 2.2, p < 0.01).

Conclusion SR in somnological consultations provides superior diagnostic quality, higher temporal efficiency and increased user satisfaction in everyday clinical practice. For this reason, SR should be recommended for sleep medicine.

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Artikel online veröffentlicht:
10. Juni 2020