Willer B, Santoro E
Hosp Community Psychiatry. 1975 Jun;26(6):362-5. doi: 10.1176/ps.26.6.362.
This study examined the frequency, length, and content of staff's discussions and written reports about 90 hospitalized psychiatric patients. The reporting habits of staff on three different units of one hospital were compared. On the units where nursing staff were primary case managers, discussion was less likely to include mention of treatment goals or plans than where psychiatrists were case managers, or where nursing staff were case managers and patients were encouraged to attend case reviews. There was no difference between the units on recording habits, but nursing staff were consistently more dependable than psychiatrist at record-keeping.
本研究调查了工作人员关于90名住院精神科患者的讨论及书面报告的频率、篇幅和内容。对一家医院三个不同科室工作人员的报告习惯进行了比较。在护理人员为主要病例管理者的科室,与精神科医生为病例管理者的科室或护理人员为病例管理者且鼓励患者参加病例评审的科室相比,讨论中提及治疗目标或计划的可能性较小。各科室在记录习惯上没有差异,但在记录保存方面,护理人员始终比精神科医生更可靠。