Raval Amish N, Marchiori Gordon E, Arnold J Malcolm O
Division of Cardiology, London Health Sciences Centre, Department of Medicine, University of Western Ontario, Lawson Health Research Institute, London, Canada.
Can J Cardiol. 2003 Mar 31;19(4):365-70.
To determine the adequacy of the discharge summary in reporting important investigative results and future management plans in patients hospitalized and discharged with a diagnosis of heart failure.
During a six-month period, all patient charts were identified and reviewed in which heart failure had been the most responsible discharge diagnosis. Trained, independent chart reviewers recorded predefined key aspects of the typed and handwritten discharge summaries including measurement of left ventricular function, utilization of angiotensin-converting enzyme inhibitors (ACEI), management of risk factors, and instructions for follow-up treatment and appointments.
Single centre, tertiary care teaching hospital.
One hundred and one patient charts meeting review criteria were identified. Eighty-two contained a typed (dictated) discharge summary and 82 contained a copy of a one-page preformatted but handwritten summary given to the patient at discharge with instructions to give to their primary care physician. Forty-one per cent of typed discharge summaries did not record any known evaluation of left ventricular ejection fraction (LVEF). Of patients with LVEF < or =40%, 34% were not prescribed an ACEI at time of discharge. Of these patients, a contraindication was documented in 26% but there was no documentation of a contraindication or reason in 24%. In patients with ischemic cardiomyopathy as the principal attributed cause of heart failure, 80% of discharge summaries had no specific instructions addressing modifiable risk factors. Follow-up instructions for family physician visits were not mentioned in 56% of typed discharge summaries.
Substantial inadequacies exist in communicating to the community physician, at the time of discharge from an acute care teaching hospital, valuable patient management information of patients with heart failure. This may have implications for continuity of care and subsequent clinical outcomes.
确定出院小结在报告因心力衰竭住院并出院患者的重要检查结果和未来管理计划方面是否充分。
在六个月期间，识别并审查所有以心力衰竭为主要出院诊断的患者病历。经过培训的独立病历审查员记录打印和手写出院小结的预定义关键方面，包括左心室功能测量、血管紧张素转换酶抑制剂（ACEI）的使用、危险因素管理以及后续治疗和预约的指示。
单中心三级护理教学医院。
确定了101份符合审查标准的患者病历。82份包含打印（口述）出院小结，82份包含出院时给患者的一页预格式化但手写小结的副本，并指示患者交给其初级保健医生。41%的打印出院小结未记录任何已知的左心室射血分数（LVEF）评估。在LVEF≤40%的患者中，34%在出院时未开具ACEI。在这些患者中，26%记录了禁忌证，但24%未记录禁忌证或原因。在以缺血性心肌病为心力衰竭主要归因原因的患者中，80%的出院小结没有针对可改变危险因素的具体指示。56%的打印出院小结未提及家庭医生随访的后续指示。
在急性护理教学医院出院时，向社区医生传达心力衰竭患者的重要患者管理信息存在严重不足。这可能对护理连续性和随后的临床结果产生影响。
