电子病历实施后手术出院小结的及时性和质量。

Timeliness and quality of surgical discharge summaries after the implementation of an electronic format.

机构信息

Department of Surgery, Division of Surgery Education, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA 19104, USA; Center for Healthcare Improvement and Patient Safety, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Department of Surgery, Division of Surgery Education, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA 19104, USA.

出版信息

Am J Surg. 2014 Jan;207(1):7-16. doi: 10.1016/j.amjsurg.2013.04.003. Epub 2013 Oct 23.

DOI:10.1016/j.amjsurg.2013.04.003

PMID:24269034

Abstract

BACKGROUND

As electronic discharge summaries (EDS) become more prevalent and health care systems increase their focus on transitions of care, analysis of EDS quality is important. The objective of this study was to assess the timeliness and quality of EDS compared with dictated summaries for surgical patients, which has not previously been evaluated.

METHODS

A retrospective study was conducted of a sample of discharge summaries from surgical patients at an urban university teaching hospital before and after the implementation of an EDS program. Summaries were evaluated on several dimensions, including time to summary completion, summary length, and summary quality, which was measured on a 13-item scoring tool.

RESULTS

After the exclusion of 5 patients who died, 195 discharge summaries were evaluated. Discharge summaries before and after EDS implementation were similar in admission types and discharge destinations of the patients. Compared with dictated summaries, EDS had equivalent overall quality (P = .11), with higher or equivalent scores on all specific quality aspects except readability. There was a highly significant statistical and clinical improvement in timeliness for electronic summaries (P < .01). Obvious use of copying and pasting was identified in 8% of discharge summaries and was associated with decreased readability (P = .02).

CONCLUSIONS

The implementation of EDS can improve the timeliness of summary completion without sacrificing quality for surgical patients. Excessive copying and pasting can reduce the readability of discharge summaries, and strategies to discourage this practice without the use of appropriate editing should be used.

摘要

背景

随着电子出院小结（EDS）的日益普及以及医疗保健系统对医疗护理交接工作的日益重视，分析 EDS 的质量变得尤为重要。本研究旨在评估 EDS 与外科患者的口述摘要相比的及时性和质量，而这一点此前尚未得到评估。

方法

本研究对一所城市大学教学医院的外科患者的出院小结进行了回顾性研究，这些出院小结在实施 EDS 计划之前和之后各有一部分。从几个方面评估了这些小结，包括完成摘要的时间、摘要的长度以及摘要的质量，后一方面通过一个包含 13 个项目的评分工具进行衡量。

结果

排除 5 例死亡患者后，共评估了 195 份出院小结。实施 EDS 前后的出院小结在患者的入院类型和出院目的地方面相似。与口述摘要相比，EDS 的整体质量相当（P=0.11），除了可读性之外，所有特定质量方面的评分都更高或相当。电子摘要在及时性方面有显著的统计和临床改善（P<0.01）。在 8%的出院小结中发现了明显的复制和粘贴用法，这与可读性降低有关（P=0.02）。