Najim Hellme, Jaffar Khalid
South Essex University Foundation NHS Trust, Basildon University Hospital, Basildon, Essex SS16 5NL, UK,
Psychiatr Danub. 2015 Sep;27 Suppl 1:S432-4.
Patients discharge summaries are important as they record a vital miles stone in patients' care. Their accurate record improves patients' care and clarifies communication between different health professionals.
60 Discharge summaries from different consultant psychiatrists' case load were audited. The results were analysed and presented with recommendations to improve them a format was suggested. A reaudit of 62 discharge summaries was carried out by the same team after three years in the same catchment area but the practice has changed to inpatient and community.
Improvement in most of the areas audited occur in the reaudit which indicates the usefulness of audit in improving clinical practice which a pivotal part of clinical governance.
This completed audit cycle has proven that clinical practice has been reviewed and methods of improving it have been implemented. It has been noted that more items were reviewed and added to the second cycle which should be condoned.
Discharge summaries are important clinical documents in secondary and primary care communications. They are helpful for secondary care staff as they good references for people in out of hours services and Accident and Emergency. Good quality discharge summaries improve patients care and make it easy to manage clinical risk.
患者出院小结很重要,因为它们记录了患者治疗过程中的一个重要里程碑。其准确记录可改善患者护理,并明晰不同医疗专业人员之间的沟通。
对来自不同精神科顾问医生病例量的60份出院小结进行审核。分析结果并提出改进建议,同时建议了一种格式。三年后,同一团队在同一服务区域对62份出院小结进行了重新审核,但业务范围已变为住院和社区服务。
重新审核时,大多数审核领域都有改进,这表明审核对改善临床实践有用,而临床实践是临床治理的关键部分。
这个完整的审核周期证明了临床实践已得到审查,且改进方法已得到实施。值得注意的是,第二个周期审查和增加了更多项目,这是可以接受的。
出院小结是二级和初级医疗沟通中的重要临床文件。它们对二级医疗人员很有帮助,因为它们是非工作时间服务人员和急诊人员的良好参考。高质量的出院小结可改善患者护理,并便于管理临床风险。