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医院出院报告:内容与设计

Hospital discharge reports: content and design.

作者信息

Tulloch A J, Fowler G H, McMullan J J, Spence J M

出版信息

Br Med J. 1975 Nov 22;4(5994):443-6. doi: 10.1136/bmj.4.5994.443.

Abstract

The information required by family doctors on initial and final discharge reports from hospitals was specified and 546 such reports from hospitals in Aylesbury, Amersham, Banbury, Oxford, and High Wycombe were reviewed for the availability and accessibility of important information. Several items could have been recorded better, including the name of the hospital, the specialty (or department) concerned, and the name of the consultant in charge of the case. Drug reactions seemed to be under-reported in the initial discharge reports and information about treatment on discharge was inadequate. The recording of the prognosis and information given to the patient was deficient and communication on follow-up needs to be improved. The use of obscure abbreviations was widespread. There is room for improvement in the ease of access to important information, especially the diagnostic assessment, and the time taken for final reports to reach the general practitioner.

摘要

明确了家庭医生在医院初次出院报告和最终出院报告中所需的信息,并对来自艾尔斯伯里、阿默舍姆、班伯里、牛津和海威科姆等地医院的546份此类报告进行了审查,以了解重要信息的可获取性和易获取性。有几个项目本可以记录得更好,包括医院名称、相关专科(或科室)以及负责该病例的顾问姓名。药物不良反应在初次出院报告中似乎报告不足,出院时的治疗信息也不充分。预后记录以及向患者提供的信息存在缺陷,后续随访的沟通需要改进。晦涩缩写的使用很普遍。在获取重要信息的便捷性方面,尤其是诊断评估方面,以及最终报告送达全科医生所需的时间方面,仍有改进空间。

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