van Walraven C, Weinberg A L
Department of Internal Medicine, University of Ottawa, Ont.
CMAJ. 1995 May 1;152(9):1437-42.
To assess the completeness of hospital discharge summaries and the efficiency of the discharge summary system in two urban teaching hospitals.
Descriptive study, with follow-up telephone survey.
General internal medicine services at two urban tertiary care hospitals affiliated with the University of Ottawa.
A total of 135 patient charts, representing 10% of the patients discharged from the services between Aug. 1 and Dec. 31, 1993. Three charts were unavailable for review, and 26 were excluded because of patient death, early patient discharge (within 48 hours after admission) or lack of discharge summary; this left 106 summaries for analysis of completeness and 114 (including the charts without a summary) for analysis of efficiency.
Completeness: proportion of summaries in which the following information was reported: admission diagnosis, drug allergies, physical examination, significant laboratory tests and results, discharge diagnosis, discharge medications and medical follow-up. Efficiency: time taken to generate the discharge summary and whether the patient's family physician received it.
Of the 106 charts with a discharge summary, information was available from the dictation system database for all but one (99.1% complete). Information was missing on the admission diagnosis in 34.0% (36/106) of the summaries, the discharge diagnosis in 25.5% (27/106) and the discharge medications in 22.8% (23/101). Of the 268 significant laboratory tests and results noted in the charts 115 (42.9%) were not reported in the discharge summary. Of the 94 discharge summaries in charts with the patient's family physician listed on the facesheet, 38 (40.4%) were not received by the family physician.
Considerable deficiencies in the completeness of the discharge summaries and the efficiency of the discharge summary system were found in the participating hospitals. Replication of this study in other settings is indicated, and strategies to improve the process should be pursued.
评估两家城市教学医院出院小结的完整性以及出院小结系统的效率。
描述性研究，采用随访电话调查。
渥太华大学附属的两家城市三级医疗医院的普通内科服务部门。
共135份患者病历，占1993年8月1日至12月31日期间该服务部门出院患者的10%。3份病历无法用于审查，26份因患者死亡、患者提前出院（入院后48小时内）或缺少出院小结而被排除；这留下106份小结用于完整性分析，114份（包括没有小结的病历）用于效率分析。
完整性：报告以下信息的小结比例：入院诊断、药物过敏、体格检查、重要实验室检查及结果、出院诊断、出院用药和医疗随访。效率：生成出院小结所需时间以及患者的家庭医生是否收到小结。
在106份有出院小结的病历中，除1份外，所有病历的信息均可从听写系统数据库中获取（完成率99.1%）。34.0%（36/106）的小结中缺少入院诊断信息，25.5%（27/106）缺少出院诊断信息，22.8%（23/101）缺少出院用药信息。病历中记录的268项重要实验室检查及结果中，115项（42.9%）未在出院小结中报告。在病历首页列出患者家庭医生的94份出院小结中，38份（40.4%）未被家庭医生收到。
参与研究的医院在出院小结的完整性和出院小结系统的效率方面存在相当大的不足。建议在其他环境中重复此研究，并应寻求改进该流程的策略。
