Kannry Joseph, Moore Carlton, Karson Tom
Center for Medical Informatics, Mount Sinai Medical Center, NY, NY, USA.
AMIA Annu Symp Proc. 2003;2003:341-5.
Medical problems left unresolved during hospitalizations (along with recommended outpatient evaluations, test results pending at discharge, and discharge medication regimens) are often documented in patients' discharge summaries. However, studies have demonstrated that discharge summaries are frequently unavailable or inaccessible at post discharge visit(s). Interim discharge summaries have been shown to improve the flow of information between inpatient and outpatient physicians. We have constructed a web-based solution, discharge communiqués that are very much like interim discharge summaries but are an automatic byproduct of an every day workflow process, signout. The New SignOut System captures signout information and generates discharge communiqués immediately upon discharge. From June 2002-January 2003 7926 discharge communiqués were made available on 7926 patients and there were 12,920 look-ups of communiqués. Studies concur that 40-50% of patients will not have an available discharge summary making communiqués the primary source of clinical information on prior hospitalization for outpatient physicians.
住院期间未解决的医疗问题(以及推荐的门诊评估、出院时待处理的检查结果和出院药物治疗方案)通常会记录在患者的出院小结中。然而,研究表明,出院小结在出院后复诊时常常无法获取或难以获得。临时出院小结已被证明可改善住院医师和门诊医师之间的信息流通。我们构建了一个基于网络的解决方案,即出院公报,它与临时出院小结非常相似,但却是日常工作流程“交班”的自动产物。新的交班系统会捕捉交班信息,并在出院时立即生成出院公报。在2002年6月至2003年1月期间,为7926名患者提供了7926份出院公报,公报的查阅次数为12920次。研究一致认为,40%至50%的患者没有可用的出院小结,这使得公报成为门诊医师了解患者先前住院临床信息的主要来源。