Derkx Hay, Rethans Jan-Joost, Muijtjens Arno, Maiburg Bas, Winkens Ron, van Rooij Harrie, Knottnerus André
Maastricht University, Maastricht, The Netherlands.
Qual Saf Health Care. 2010 Dec;19(6):e1. doi: 10.1136/qshc.2008.027920. Epub 2010 Jun 27.
To assess the quality of the content of reports of telephone consultations at out-of-hours centres and to investigate to what extent the reports reflect the actual telephone consultation.
Cross-sectional qualitative study; 17 out-of-hours centres in The Netherlands.
To assess the quality of the content of reports, a focus group developed the Reason for calling, Information gathered, Care advice given, Evaluation of the care advice with the patient (RICE) report rating instrument. Telephone Incognito Standardised Patients presented seven different clinical problems three times to 17 out-of-hours centres. All calls were recorded and transcribed. The out-of-hours centres being called were asked for a copy of the report of the call. The authors assessed the quality of the content of the reports and compared this with the transcripts.
The out-of-hours centres returned a report for 78% of the 357 calls. For the remaining 22% of the calls, no report was written. Reports contained almost always information about the medical reason for calling but little information about details of the clinical history. Patients' expectation, personal situation or perception of the care advice was seldom documented. In all but one out-of-hours centre, answers to obligatory questions were reported by triagists, although they had not been asked, varying between 1% and 54% of all questions entered. Triagists entered a subjective evaluation of a patients' condition in 12% of the reports.
Reports of telephone consultations of out-of-hours centres contained little information on patients' clinical and personal condition. This could potentially endanger patients' continuity of care and might pose legal consequences for the triagist.
评估非工作时间中心电话咨询报告的内容质量，并调查这些报告在多大程度上反映了实际的电话咨询情况。
横断面定性研究；荷兰的17个非工作时间中心。
为评估报告内容质量，一个焦点小组开发了呼叫原因、收集的信息、给出的护理建议、与患者一起对护理建议的评估（RICE）报告评级工具。电话匿名标准化患者向17个非工作时间中心三次呈现七个不同的临床问题。所有通话均进行记录和转录。要求被呼叫的非工作时间中心提供通话报告副本。作者评估了报告内容的质量，并将其与转录本进行比较。
非工作时间中心为357次通话中的78%返回了报告。对于其余22%的通话，未撰写报告。报告几乎总是包含呼叫的医学原因信息，但关于临床病史细节的信息很少。患者的期望、个人情况或对护理建议的看法很少被记录。除一个非工作时间中心外，所有中心的分诊人员都报告了对必问问题的回答，尽管并未询问这些问题，报告的问题占所有录入问题的1%至54%不等。分诊人员在12%的报告中对患者病情进行了主观评估。
非工作时间中心的电话咨询报告包含的患者临床和个人情况信息很少。这可能会危及患者的连续护理，并可能给分诊人员带来法律后果。
