Rubak S L, Mainz J
Aarhus Universitet, Institut for Almen Medicin.
Ugeskr Laeger. 2000 Jan 31;162(5):648-53.
The study was partly based on a retrospective analysis of 408 hospital referrals and 261 discharge summary letters and partly on interviews with chief physicians/surgeons and general practitioners. The level of information in hospital referrals: patient history 87%, objective findings 94%, social medicine 31%, plan/expectations 21%. The diagnostic applicability of patient history/objective findings was 95% and social medicine 70%. The discharge summary letter was received 2-3 days after hospital discharge in 17% cases. In the discharge letters information about medication was described in 41%, information given to patient/relatives in 9%. When discharge summary letters from departments of internal medicine and surgery were compared the level of informations from departments of internal medicine to departments of surgery was superior e.g. descriptions of medication (62% against 26%), date of control (34% against 24%) and information to patient/relatives (12% against 5%). The conclusion was that the level of information and the diagnostic applicability showed variation with regard to quality. General practitioners and hospitals must develop guidelines for hospital referrals and discharge summary letters in order to improve the patient's course.
该研究部分基于对408份医院转诊记录和261份出院小结的回顾性分析，部分基于对主任医师/外科医生和全科医生的访谈。医院转诊记录中的信息水平：患者病史87%，客观检查结果94%，社会医学31%，计划/期望21%。患者病史/客观检查结果的诊断适用性为95%，社会医学为70%。17%的病例在出院后2 - 3天收到出院小结。出院小结中，41%提到了用药信息，9%提到了向患者/家属提供的信息。比较内科和外科的出院小结时，内科提供的信息水平高于外科，例如用药描述（62%对26%）、复查日期（34%对24%）以及向患者/家属提供的信息（12%对5%）。结论是信息水平和诊断适用性在质量方面存在差异。全科医生和医院必须制定医院转诊和出院小结的指导方针，以改善患者的治疗过程。
