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[卡斯蒂利亚-拉曼恰地区内科服务所撰写的出院报告质量(临床数据评估)]

[Quality of discharge reports prepared by the services of internal medicine in Castilla-La Mancha (assessment of clinical data)].

作者信息

Viana Alonso A, Portillo Pérez-Olivares H, Rodríguez Rodríguez A, Hernández Lanchas C, Rosa Herranz C, de la Morena Fernández J

机构信息

Servicio de Medicina Interna, Estudio Multicéntrico Castilla-La Mancha, Hospital Universitario, Guadalajara.

出版信息

An Med Interna. 1993 Jun;10(6):280-2.

PMID:8334205
Abstract

We analyzed several aspects of the quality (at the level of clinical data) of discharge reports prepared by the Services of Internal Medicine in the hospitals of Castilla-La Mancha, taking into account that these are the end written products of the health care activity. We analyzed 800 reports and we found terms such as "probably, not discarded" in the clinical judgment in 150 reports out of 794 and abbreviations in 370 out of 792. 10.8% of the reports written at discharge (86 out of 794) were waiting for the results, reflecting thus severe shortcomings in the clinical data of these reports, that must be corrected in our area.

摘要

我们分析了卡斯蒂利亚-拉曼恰地区医院内科服务部门编制的出院报告(在临床数据层面)的几个质量方面,考虑到这些报告是医疗保健活动的最终书面成果。我们分析了800份报告,发现在794份报告中的150份临床判断中存在“可能,未排除”等术语,在792份报告中的370份存在缩写。出院时撰写的报告中有10.8%(794份中的86份)在等待结果,这反映出这些报告的临床数据存在严重缺陷,必须在我们地区加以纠正。

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