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如何撰写精神科会诊报告。

How to write a psychiatric consultation.

作者信息

Garrick T R, Stotland N L

出版信息

Am J Psychiatry. 1982 Jul;139(7):849-55. doi: 10.1176/ajp.139.7.849.

Abstract

The written psychiatric consultation is the distillation, the official permanent record, and the one universal element of the consultation process. Both the document and process present a good and growing opportunity for service and teaching. The authors offer a conceptual and practical scheme to help potential consultants make decisions about the content, style, and wording of their written communications. Each of the components of the consultation document, including headings, openings, history, examination, and formulations, is considered in terms of its effects on the liaison with the consultee and the care of the patient.

摘要

书面精神科会诊是会诊过程的精髓、官方永久记录以及一个通用要素。该文件和过程为服务与教学提供了良好且不断增长的机会。作者提供了一个概念性和实用性的方案,以帮助潜在的会诊医生就其书面交流的内容、风格和措辞做出决策。会诊文件的每个组成部分,包括标题、开头、病史、检查和诊断,都从其对与会诊医生的联络以及患者护理的影响方面进行了考量。

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