Frings Julian, Rust Paul, Meister Sven, Prinz Christian, Fehring Leonard
Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.
Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.
J Gen Intern Med. 2025 May;40(6):1387-1402. doi: 10.1007/s11606-025-09395-9. Epub 2025 Feb 6.
The diagnosis section in hospital discharge summaries is critical for continuity of care and patient safety, yet it varies widely in quality, format, and content due to a lack of standards.
This study aims to develop a cross-specialty standard for the structure and content of the diagnosis section, based on the preferences of German physicians. The study examines physicians' satisfaction with the diagnosis section, their rating of its importance, and their preferences for its specific elements, comparing perspectives between inpatient and outpatient physicians.
DESIGN, PARTICIPANTS, APPROACH: This mixed-methods study integrated a scoping review, focus group discussion, and a nationwide survey of 602 physicians (317 outpatient primary care and 285 inpatient physicians; 4.1% response rate), most trained in internal medicine. Quantitative analyses evaluated physician satisfaction and preferences, while qualitative feedback provided deeper insights regarding preferred content and format.
Although 95.7% of physicians considered the diagnosis section crucial for follow-up care, only 36.9% were satisfied with its current content and format. 91.2% supported standardizing the diagnosis section, identifying 18 content elements to be included for every current treatment diagnosis. Strong consensus (> 95.0% agreement) was reached for "name of the diagnosis," "severity/stage/classification/TNM," "localization/extent/pattern of involvement," "course e.g., acute, chronic, recurrent," "expression," "complications," "date of initial diagnosis," and "etiology/cause." 86.4% preferred separating current and chronic/prior diagnoses with headings. Outpatient physicians were more likely than inpatient physicians to rate "ICD-10 codes" as mandatory (46.2% vs. 14.8%, p < 0.001) and to consider "recommendations for further procedures" (76.6% vs. 63.6%, p < 0.001) and "follow-up appointments" (77.3% vs. 63.5%, p < 0.001) as necessary. Additionally, a list of practical recommendations for clinicians to better document diagnoses was derived.
This study proposes a cross-specialty standard for the diagnosis section based on physician preferences for a clearly structured format and 18 key content elements.
医院出院小结中的诊断部分对于持续护理和患者安全至关重要，但由于缺乏标准，其质量、格式和内容差异很大。
本研究旨在根据德国医生的偏好，制定一份关于诊断部分结构和内容的跨专业标准。该研究考察医生对诊断部分的满意度、对其重要性的评级以及对其具体要素的偏好，比较住院医生和门诊医生的观点。
设计、参与者、方法：这项混合方法研究综合了范围综述、焦点小组讨论以及对602名医生（317名门诊初级保健医生和285名住院医生；回复率4.1%）的全国性调查，这些医生大多接受过内科培训。定量分析评估医生的满意度和偏好，而定性反馈则提供了关于首选内容和格式的更深入见解。
尽管95.7%的医生认为诊断部分对后续护理至关重要，但只有36.9%的医生对其当前内容和格式感到满意。91.2%的医生支持对诊断部分进行标准化，确定了每个当前治疗诊断应包含的18个内容要素。对于“诊断名称”“严重程度/阶段/分类/TNM”“定位/范围/受累模式”“病程（如急性、慢性、复发性）”“表现”“并发症”“初次诊断日期”和“病因/原因”达成了强烈共识（>95.0%的一致性）。86.4%的医生倾向于用标题区分当前诊断和慢性/既往诊断。门诊医生比住院医生更有可能将“ICD - 10编码”列为必填项（46.2%对14.8%，p < 0.001），并认为“进一步检查建议”（76.6%对63.6%，p < 0.001）和“随访预约”（77.3%对63.5%，p < 0.001）是必要的。此外，还得出了一份供临床医生更好记录诊断的实用建议清单。
本研究基于医生对清晰结构化格式和18个关键内容要素的偏好，提出了诊断部分的跨专业标准。
