回顾性分析一家三级护理医院肿瘤内科的出院小结：评估是否符合推荐的出院小结内容的记录要求。
A retrospective analysis of discharge summaries from a tertiary care hospital medical oncology unit: To assess compliance with documentation of recommended discharge summary components.
机构信息
ANU Medical School, Australian National University, Canberra, Australia.
Department of Medical Oncology, the Canberra Hospital, Garran, Australia.
出版信息
Cancer Rep (Hoboken). 2022 Feb;5(2):e1457. doi: 10.1002/cnr2.1457. Epub 2021 Jun 21.
BACKGROUND
Discharge summaries are essential for health transition between inpatient hospital teams and outpatient general practices. The patient's outcome is dependent on the quality and timeliness of discharge summaries.
AIM
A retrospective analysis was carried out to assess the compliance with recommended documentation of 697 electronic discharge summaries (eDSs) of oncology inpatients discharged in 2018 from the Canberra Hospital according to the National Guidelines of On-Screen Presentation of Discharge Summaries.
METHODS AND RESULTS
Individual medical records were identified and screened for the recommended eDS components according to the National Guidelines. Out of the 17 recommended components, nine components were included in all discharge summaries, two components in more than 99% and two components in 95-96% of discharge summaries. The most frequently omitted components include "information provided to the patient," "ceased medicine" and "procedures," and these were omitted in 8, 38 and 82% of discharge summaries, respectively.
CONCLUSION
Overall, most discharge summaries adhered to the national guidelines quite well by including most of the recommended components. However, the discharge summary quality is still inadequate in some domains.
背景
出院小结对于医院内团队和门诊普通科之间的健康交接至关重要。患者的转归取决于出院小结的质量和及时性。
目的
对 2018 年堪培拉医院出院的 697 份肿瘤住院患者电子出院小结（eDS）进行回顾性分析，根据《屏幕显示出院小结国家指南》评估其对推荐文档记录的依从性。
方法和结果
根据国家指南，对个别病历进行了识别，并对推荐的 eDS 成分进行了筛选。在 17 项推荐的成分中，有 9 项出现在所有出院小结中，2 项出现在 99%以上的出院小结中，2 项出现在 95-96%的出院小结中。最常遗漏的部分包括“向患者提供的信息”、“停止使用的药物”和“程序”，分别有 8%、38%和 82%的出院小结遗漏了这些内容。
结论
总体而言，大多数出院小结通过包含大多数推荐的成分很好地遵循了国家指南。然而，在某些领域，出院小结的质量仍然不足。
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