Schuman J E, Ostfeld A M, Willard H N
Arch Phys Med Rehabil. 1976 Jul;57(1):343-7.
To improve discharge planning on an acute medical ward, a nursing "team system" was initiated with clear delineation of responsibility for discharge planning. The head nurse supervised the nurses' actions and supported their communication with attending physicians. To assess the efficacy of this approach, chart reviews and interviews of 60 consecutive patients were performed before and after the implementation of the plan. A plan was labeled adequate if the following criteria were met: all treatable diagnoses were recognized; appropriate treatment regimens were instituted for each diagnosis; the patient's abilities were sufficient for him to function in the proposed environment; and plans were made for follow-up care. Patient knowledge was stated to be adequate if the patient was aware of his diagnosis, treatment regimen and plans for follow-up care. In addition, the patient was questioned concerning his satisfaction with the plans for further care. Seventy-five percent of the patients admitted to this ward required discharge planning. Of those requiring discharge planning, the plan was judged adequate in 55% prior to the program change and in 83% following that change. Eighty percent of the patients required some teaching during their hospital stay. Of these, by the time of discharge, knowledge was adequate in 53% prior to the program change and 51% subsequent to the change. Initially 68% of the patients were very satisfied with the discharge plans but this figure rose to 86% following the program change.
为改善急性内科病房的出院计划，启动了一种护理“团队系统”，明确划分出院计划的责任。护士长监督护士的行动，并支持他们与主治医生的沟通。为评估该方法的效果，在计划实施前后对60例连续患者进行了病历审查和访谈。如果满足以下标准，则将计划标记为充分：所有可治疗的诊断均得到确认；针对每个诊断制定了适当的治疗方案；患者的能力足以使其在所建议的环境中发挥作用；并制定了后续护理计划。如果患者了解自己的诊断、治疗方案和后续护理计划，则称患者的知识充分。此外，还询问了患者对进一步护理计划的满意度。该病房收治的患者中有75% 需要出院计划。在需要出院计划的患者中，计划在项目变更前被判定为充分的占55%，变更后为83%。80% 的患者在住院期间需要一些指导。其中，到出院时，知识在项目变更前充分的占53%，变更后为51%。最初，68% 的患者对出院计划非常满意，但该数字在项目变更后升至86%。
