Cheah Lean-Peng, Amott Debbie H, Pollard James, Watters David A K
St. Vincent's Hospital, Melbourne, VIC.
Med J Aust. 2005 Oct 3;183(7):369-72. doi: 10.5694/j.1326-5377.2005.tb07086.x.
As the working hours of junior doctors decrease, adequate handover of patients becomes more important to maintain continuity of care and avoid errors caused by information gaps. A minimum dataset for surgical handover should include the patient's name, location (ward and bed number), date of admission, diagnosis, procedure (with date), complications and progress, management plan, resuscitation plan, consultant availability (and instructions if not available), expected need for review, and name of doctor completing handover and date to confirm that information is current. An electronic handover system is a potential solution, but our survey shows that free-text entry into such systems may be inadequate; prompts or predefined fields for handover content are possible solutions.
随着初级医生工作时间的减少，充分进行患者交接对于维持护理的连续性以及避免因信息缺口导致的错误变得更为重要。手术交接的最小数据集应包括患者姓名、位置（病房和床号）、入院日期、诊断、手术（及日期）、并发症及病情进展、管理计划、复苏计划、会诊医生可用性（若不可用则注明指示）、预期复查需求，以及完成交接的医生姓名和日期，以确认信息的时效性。电子交接系统是一个潜在的解决方案，但我们的调查显示，在此类系统中采用自由文本录入可能并不充分；针对交接内容设置提示或预定义字段可能是解决办法。
