Navarro C M, Miranda I A N, Onofre M A, Sposto M R
Araraquara Dental School-UNESP, Faculdade de Odontologia, Oral Medicine Service, Department of Diagnosis and Surgery, São Paulo, Brazil.
Int J Oral Maxillofac Surg. 2002 Oct;31(5):537-43. doi: 10.1054/ijom.2002.0277.
Usually referral letters are the only means of communication between general practitioners and specialists in the health area. However, they are inadequate if important basic data are omitted. The aim of this study was to compare the content of standard and non-standard letters. A total of 1956 files from the Oral Medicine Service were consecutively evaluated (March 1996 to September 2000). Key items were considered for analysis and the results were stored in a database using the Epinfo 6.04 program. The chi2 test (alpha=0.05) was applied to the results. Of the 1956 files examined, 34% (662) had a referral letter, 31% of them being standard letters and 69% non-standard letters. Most standard letters (87%) were from professionals of public health institutions. Most percent discrepancies between standard and non-standard letters were observed for patient address (14.90 vs 1.32%), patient age (54.81 vs 9.47%), chief complaint (32.21 vs 8.37%), fundamental lesion (29.33 vs 13.66%), and symptoms (27.81 vs 15.42%). Statistically significant differences were observed for patient age, professional referring the patient, chief complaint, and site of the lesion. The quality and quantity of the information differed significantly between the two types of letters. The standard letters were more complete and contained information commonly absent in the non-standard letters. We suggest the use of standard letters for improving the quality of communication among professionals.
通常情况下，转诊信是医疗卫生领域全科医生与专科医生之间唯一的沟通方式。然而，如果重要的基础数据被遗漏，转诊信就不够充分。本研究的目的是比较标准信件和非标准信件的内容。对口腔医学科1956份病历（1996年3月至2000年9月）进行了连续评估。分析时考虑了关键项目，并使用Epinfo 6.04程序将结果存储在数据库中。对结果应用卡方检验（α = 0.05）。在检查的1956份病历中，34%（662份）有转诊信，其中31%为标准信件，69%为非标准信件。大多数标准信件（87%）来自公共卫生机构专业人员。标准信件和非标准信件在患者地址（14.90%对1.32%）、患者年龄（54.81%对9.47%）、主诉（32.21%对8.37%）、基本病变（29.33%对13.66%）和症状（27.81%对15.42%）方面的差异百分比最大。在患者年龄、转诊患者的专业人员、主诉和病变部位方面观察到统计学上的显著差异。两种类型信件的信息质量和数量有显著差异。标准信件更完整，包含非标准信件中通常缺少的信息。我们建议使用标准信件来提高专业人员之间的沟通质量。
