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门诊信件:要求与内容。

Out-patient letters: requirement and contents.

作者信息

Young D W, Parkes J, Davis W A, Harman D, Williams R S

出版信息

Eff Health Care. 1985;2(6):225-9.

Abstract

Twenty-five general practitioners were interviewed about the contents of out-patient letters. There was universal agreement on the need for the following information: diagnosis, abnormal physical findings, abnormal routine and non-routine test results, changes in treatment, comments on the patient's physical condition and disposal. The contents of 215 out-patient letters were analysed and the results compared with the GPs' views. There was little difference in the letters from medical and surgical clinics. Both were deficient to a limited extent in the reporting of abnormal test results, the reasons for, and significance of investigations, and in detailing the information given to patients.

摘要

就门诊信件的内容对25名全科医生进行了访谈。对于以下信息的必要性,大家达成了普遍共识:诊断、异常体征、常规和非常规检查结果异常、治疗变化、对患者身体状况的评论以及处理意见。对215封门诊信件的内容进行了分析,并将结果与全科医生的观点进行了比较。内科和外科诊所的信件差异不大。两者在报告异常检查结果、检查的原因和意义以及详细说明向患者提供的信息方面都存在一定程度的不足。

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