[卡斯蒂利亚-拉曼恰内科服务出院报告的质量（结构评估）]
[The quality of the discharge reports from the internal medicine services of Castilla-La Mancha (a structural evaluation)].
作者信息
Viana Alonso A, Herranz C R, Portillo Pérez-Olivares H, Rodríguez Rodríguez A, Hernández Lanchas C, de la Morena Fernández J
机构信息
Servicio de Medicina Interna, Estudio Multicéntrico Castilla-La Mancha.
出版信息
An Med Interna. 1994 Jan;11(1):4-8.
UNLABELLED
The discharge report is one of the final outputs of the health care activity. We have tried to analyze several aspects related to its quality. For this purpose, we conducted a cross-sectional study analyzing 800 reports of patients admitted in the services of Internal Medicine at 6 hospitals of Castilla-La Mancha during the year 1991. We must stress the absence of discharge reports for death patients and the failure to record drug allergies (69.9%), medical history (10.4%) and time of evolution of the disease (16.9%), as well as treatment in 17 reports out of 781 and follow-up review after discharge in 12.8%.
CONCLUSIONS
Discharge reports have a low scientific content and the production of this type of records is not a routine practice in the case of death patients.
未加标注
出院报告是医疗活动的最终产出之一。我们试图分析与其质量相关的几个方面。为此，我们进行了一项横断面研究，分析了1991年卡斯蒂利亚 - 拉曼恰6家医院内科收治患者的800份报告。我们必须强调死亡患者没有出院报告，以及未记录药物过敏（69.9%）、病史（10.4%）和疾病进展时间（16.9%）的情况，还有781份报告中有17份未提及治疗情况，12.8%的报告未提及出院后的随访复查情况。
结论
出院报告的科学内容含量较低，对于死亡患者而言，这类记录的生成并非常规做法。
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