Department of Rehabilitation Science and Health Technology, Oslo Metropolitan University, Oslo, Norway.
Department of Neurology, Akershus University Hospital, Nordbyhagen, Lørenskog, Norway.
PLoS One. 2024 Sep 3;19(9):e0308039. doi: 10.1371/journal.pone.0308039. eCollection 2024.
Discharge summaries are important tools for communication between health care levels and can ensure continuity of rehabilitation. This study aims to gain insight into the content of discharge summaries written by hospital physiotherapists and occupational therapists regarding patients with stroke, and their adherence to recommended criteria for discharge summaries.
31 physiotherapy and multidisciplinary discharge summaries, for stroke patients discharged home from hospital with need of follow-up, were included in the study. We employed qualitative content analysis and descriptive statistics to explore and describe the content.
The physiotherapists and occupational therapists adhered to the recommended criteria for content in varying degree. The main focus for physiotherapists and occupational therapists were description of ADL, sensorimotor and general cognitive functions, they rarely report tolerance to exercise, and the specific cognitive abilities to follow instruction and learn were often omitted. Less focus was put on patients' experiences and needs during acute stroke, and description of goals were omitted in the physiotherapy discharge summaries.
While the physiotherapists and occupational therapists complement each other in their assessment of patients and inform the reader about both sensorimotor and cognitive functions and abilities, they omit some of the specific criteria for rehabilitation. Despite the omissions, the information provided is specific to the patients' function and needs.
出院小结是医疗保健各层级之间进行沟通的重要工具,可以确保康复的连续性。本研究旨在深入了解医院物理治疗师和职业治疗师为出院后需要进行后续治疗的脑卒中患者撰写的出院小结的内容,并评估其对出院小结推荐标准的遵循情况。
本研究纳入了 31 份针对出院回家的脑卒中患者的物理治疗和多学科出院小结。我们采用定性内容分析法和描述性统计方法来探索和描述内容。
物理治疗师和职业治疗师在不同程度上遵循了推荐的内容标准。物理治疗师和职业治疗师的主要关注点是日常生活活动、感觉运动和一般认知功能的描述,他们很少报告对运动的耐受性,并且经常省略具体的认知能力,如遵循指令和学习的能力。他们较少关注患者在急性脑卒中期间的体验和需求,并且物理治疗出院小结中省略了目标的描述。
尽管物理治疗师和职业治疗师在评估患者方面相互补充,并向读者提供有关感觉运动和认知功能及能力的信息,但他们忽略了一些康复的具体标准。尽管存在遗漏,但提供的信息是针对患者功能和需求的具体内容。