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[出院小结——精神病院的名片?]

[Discharge summary--business card of the psychiatric hospital?].

作者信息

Spiessl H, Cording C

机构信息

Bezirksklinikum Regensburg.

出版信息

Psychiatr Prax. 2000 Jul;27(5):239-42.

Abstract

OBJECTIVE

Hospital discharge letters represent important means of communication between clinicians and physicians in private practice. They greatly contribute to continuous patient management.

METHODS

A survey of the literature is carried out to provide a basis for an optimal psychiatric discharge letter.

RESULTS

Deficiencies in quality of discharge summaries have been mentioned in many studies. These mainly concern delay and length of the letters. Well-structured form letters are preferred. Diagnosis, results of investigations, medication, and treatment after discharge are considered the most important details in the letter.

CONCLUSIONS

Summarizing the results, the requirements for an optimal psychiatric discharge letter should be implemented in clinical practice to improve the record and also consumer satisfaction. Computer-generated discharge summaries can improve speed of delivery by using a standardized documentation system in psychiatry and new information technology.

摘要

目的

医院出院小结是临床医生与私人执业医生之间重要的沟通方式。它们对患者的持续管理有很大帮助。

方法

进行文献调查以提供优化精神科出院小结的依据。

结果

许多研究都提到了出院小结质量的不足。这些主要涉及小结的延迟和篇幅。结构良好的格式小结更受青睐。诊断、检查结果、药物治疗以及出院后的治疗被认为是小结中最重要的细节。

结论

总结结果,应在临床实践中落实对优化精神科出院小结的要求,以改善记录并提高患者满意度。通过在精神病学中使用标准化文档系统和新信息技术,计算机生成的出院小结可以提高发放速度。

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