出院小结中皮肤科会诊记录的质量：一项回顾性分析。
The quality of dermatology consultation documentation in discharge summaries: a retrospective analysis.
作者信息
Zhao Cathy Y, Ang Renette Y N, George Robert, Tan Mei-Heng, Murrell Dedee F
机构信息
Department of Dermatology, St George Hospital, Sydney, Australia.
School of Medicine, University of New South Wales, Sydney, Australia.
出版信息
Int J Womens Dermatol. 2016 Mar 2;2(1):23-27. doi: 10.1016/j.ijwd.2015.12.003. eCollection 2016 Mar.
INTRODUCTION
Good quality documentation of dermatology consults in discharge summaries allows diagnostic and therapeutic plans to be communicated to other health professionals and ensures that appropriate governmental funds are provided to dermatology departments.
METHODS
A retrospective analysis was performed of all dermatology consults seen in 2013 at a public tertiary hospital in Sydney, Australia.
RESULTS
Two hundred nineteen discharge summaries related to inpatient dermatology consultations were analysed; 80.6% of dermatology consults, 72.2% of skin biopsies, and 57.6% of diagnoses were duly included in the discharge summaries; 82.5% of the discharge summaries were completed before the discharge. The accuracy rate of diagnosis documentation was 54.5% and was correlated with clear dermatology team documentation, the use of a problems list, infectious skin diseases and junior medical staff authorship.
CONCLUSION
This study highlights the need for improvement in dermatology consult documentation in discharge summaries. It suggests the use of a problems list in discharge summaries, clarity in dermatology teams' documentations, and postdischarge follow-up.
引言
出院小结中高质量的皮肤科会诊记录能够将诊断和治疗方案传达给其他医疗专业人员，并确保向皮肤科提供适当的政府资金。
方法
对2013年澳大利亚悉尼一家公立三级医院的所有皮肤科会诊进行回顾性分析。
结果
分析了219份与住院皮肤科会诊相关的出院小结；80.6%的皮肤科会诊、72.2%的皮肤活检及57.6%的诊断被正式纳入出院小结；82.5%的出院小结在出院前完成。诊断记录的准确率为54.5%，与皮肤科团队记录清晰、使用问题清单、感染性皮肤病及初级医务人员撰写有关。
结论
本研究强调了出院小结中皮肤科会诊记录需要改进。建议在出院小结中使用问题清单，提高皮肤科团队记录的清晰度，并进行出院后随访。
Zotero 插件