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出院记录中的诊断:其可靠性如何?

Diagnoses in discharge communications: how far are they reliable?

作者信息

Adhiyaman V, Oke A, White A D, Shah I U

机构信息

Department of Geriatric Medicine, Wrexham Maelor Hospital, Clwyd, UK.

出版信息

Int J Clin Pract. 2000 Sep;54(7):457-8.

Abstract

To discover whether general practitioners are correctly notified of a patient's final diagnosis following hospital discharge, an observational study was undertaken in a district general hospital. The final diagnosis was compared with the diagnosis documented in the discharge summary and the take-home prescription. Two hundred discharges were studied. Only 163 (81%) discharge summaries and 138 (69%) take-home prescriptions had the correct diagnosis; 24 (12%) take-home prescriptions did not have any diagnosis at all. In some cases the diagnosis differed between the discharge summaries and the take-home prescriptions. Only in 122 (61%) cases was the final diagnosis correctly documented in both instances. Communication regarding diagnosis in discharge letters is less than adequate. Every effort should be made to improve this.

摘要

为了查明在患者出院后,全科医生是否能正确收到关于患者最终诊断的通知,在一家地区综合医院开展了一项观察性研究。将最终诊断与出院小结及带回家的处方中记录的诊断进行了比较。研究了200例出院情况。只有163份(81%)出院小结和138份(69%)带回家的处方有正确诊断;24份(12%)带回家的处方根本没有任何诊断。在某些情况下,出院小结和带回家的处方中的诊断有所不同。只有122例(61%)的最终诊断在这两种情况下都记录正确。出院信中关于诊断的沟通不够充分。应尽一切努力加以改进。

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