Sandler D A, Heaton C, Garner S T, Mitchell J R
Department of Medicine and Pharmacy, University Hospital, Queen's Medical Centre, Nottingham.
BMJ. 1989 Dec 16;299(6714):1511-3. doi: 10.1136/bmj.299.6714.1511.
To determine the attitudes of patients discharged from hospital and their general practitioners to a new information card giving details about admission, diagnosis, and treatment and to assess the completeness of the information on the card.
Consecutive patients discharged from the care of three consultant physicians over 16 weeks.
One general medical ward in a large teaching hospital.
A total of 275 consecutive discharges of 258 patients were studied. The mean age of patients was 60 years and mean duration of admission five days.
At discharge from the ward all study patients received an information card and a copy of the card in the form of an interim discharge letter to be delivered to their general practitioner. Patients and general practitioners were asked to complete a questionnaire giving their views on the legibility, helpfulness, quality, and quantity of the information they received. Copies of all the information cards were scrutinised for completeness.
The results were based on 208 (76%) forms returned by patients and 214 (78%) forms returned by general practitioners. Information was considered very helpful or quite helpful according to 170 (83%) forms from patients and 197 (92%) forms from general practitioners; sufficient information was provided according to 160 and 182 forms. Most patients and nearly all general practitioners thought it was a good idea to provide this information for patients at discharge. According to 125 forms from patients and 188 from general practitioners the information card was very easy or quite easy to read; 155 patients had read it at least twice and 149 were likely to refer to it again. OTHER RESULTS: The written information about the patient, the diagnosis, and what the patient had been told was generally well completed, although the date of discharge was omitted from 42 (15%) cards. Details of drugs prescribed at discharge were generally thorough.
Giving an information card to all patients at discharge was feasible and favoured by most patients and their general practitioners. Having made minor changes in design, we think that we have produced an information card that is a convenient size and will improve communication between patients, their general practitioners, and hospital doctors. We now issue this card routinely to all patients discharged from our ward and hope that it might be widely adopted.
确定出院患者及其全科医生对一张提供入院、诊断和治疗详细信息的新信息卡的态度,并评估该信息卡上信息的完整性。
连续16周内由三位顾问医师负责治疗并出院的患者。
一家大型教学医院的一个普通内科病房。
共研究了258名患者的275次连续出院情况。患者的平均年龄为60岁,平均住院时间为5天。
病房患者出院时,所有研究对象都会收到一张信息卡以及一份以临时出院信形式呈现的信息卡副本,该副本将递交给他们的全科医生。患者和全科医生需填写一份问卷,表达他们对所收到信息的易读性、实用性、质量和数量的看法。仔细检查所有信息卡副本的完整性。
结果基于患者返回的208份(76%)表格和全科医生返回的214份(78%)表格。170份(83%)患者表格和197份(92%)全科医生表格认为信息非常有用或比较有用;160份和182份表格认为提供了足够的信息。大多数患者和几乎所有全科医生都认为在患者出院时提供这些信息是个好主意。125份患者表格和188份全科医生表格表示信息卡非常容易或比较容易阅读;155名患者至少阅读了两次,149名患者可能会再次查阅。
关于患者、诊断以及告知患者内容的书面信息总体填写良好,不过42份(15%)卡片遗漏了出院日期。出院时所开药物的详细信息通常很全面。
在患者出院时向所有患者发放信息卡是可行的,并且受到大多数患者及其全科医生的欢迎。在设计上稍作修改后,我们认为我们制作出了一张尺寸合适的信息卡,它将改善患者、其全科医生和医院医生之间的沟通。我们现在常规地向我们病房出院的所有患者发放这张卡,并希望它能得到广泛采用。