Mc Larnon E, Walsh J B, Ni Shuilleabhain A
TCD/HSE Specialist Training Programme in General Practice, Department of Public Health and Primary Care, Trinity Centre for Health Sciences, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland.
Department of Medicine for the Elderly, St James's Hospital, James's Street, Dublin 8, Ireland.
Ir J Med Sci. 2016 Feb;185(1):127-31. doi: 10.1007/s11845-014-1236-7. Epub 2014 Dec 18.
The discharge document summarising an acute inpatient stay in hospital is often the only means of communication between secondary and primary care. This is especially important in the elderly population who have multiple morbidities and are often on many medications.
This study aimed to assess if information important to general practitioners is being included in inpatient hospital discharge summaries for patients of the medicine for the elderly service in a large teaching hospital.
After a thorough literature review, a "gold standard" letter was defined as having included a discharge diagnosis, medications on discharge and follow-up plans. Forty computerised discharge summaries were retrospectively assessed for inclusion of these parameters. The study group consisted of the first eight sequentially discharged patients under the care of each of the five consultants during a 1-month period (1 September 2011-30 September 2011).
A discharge diagnosis was included in 37 of the 40 summaries (92.5 %), medications on discharge were included in 39 summaries (97.5 %) and follow-up was recorded in 35 summaries (87.5 %).
This study showed that the information assessed was available in the vast majority of discharge summaries for patients admitted acutely under the care of this medicine for the elderly service. Improvements can be made, including documentation of follow-up plans.
总结急性住院患者住院情况的出院文件通常是二级医疗和初级医疗之间唯一的沟通方式。这对于患有多种疾病且通常服用多种药物的老年人群尤为重要。
本研究旨在评估一家大型教学医院老年医学科住院患者的出院小结中是否包含了对全科医生重要的信息。
在全面的文献回顾之后，将包含出院诊断、出院时用药情况和随访计划的信件定义为“金标准”信件。对40份计算机化出院小结进行回顾性评估，看是否包含这些参数。研究组由2011年9月1日至2011年9月30日这1个月期间，五位顾问医生各自负责的前八位依次出院的患者组成。
40份小结中有37份（92.5%）包含出院诊断，39份（97.5%）包含出院时用药情况，35份（87.5%）记录了随访情况。
本研究表明，对于在老年医学科接受急性治疗的患者，绝大多数出院小结中都包含了所评估的信息。仍有改进空间，包括随访计划的记录。
