Beyaert E W, Ubbink M M, Kaasenbrood A J
Psychiatrisch Centrum Amsterdam, Valeriuskliniek.
Ned Tijdschr Geneeskd. 1996 Feb 17;140(7):365-8.
Determination of the quality of discharge letters concerning psychiatric patients.
Descriptive.
29 community mental health clinics in The Netherlands.
420 hospital discharge letters were examined according to 13 quality criteria (reply time, legal status of the patient, reason for hospitalization, heteroanamnesis, source of income, alcohol use, drug use, physical findings, approach, structural diagnosis, DSM-III-R diagnosis, number of words, signature by psychiatrist) derived from a Dutch guideline for discharge letters.
The letters did not reach the aftercare attendant in time. The length of the letters was usually within 1050 words. Some formal criteria, like classification according to the DSM-III-R and signature were mostly met (in 67.1% and 90.9% of the letters). Important other information (for instance about a heteroanamnesis (24.8%), the source of income (23.1%), the use of alcohol (24%) or drugs (14.7%) and how to cope with the patient (8%)) were not sufficiently mentioned.
The quality of hospital discharge letters from community mental health clinics in The Netherlands was insufficient. Adequate exchange of information is essential to guarantee good care for psychiatric patients. Improvement of the quality of hospital discharge letters is therefore highly advisable.
确定有关精神科患者出院小结的质量。
描述性研究。
荷兰的29家社区精神卫生诊所。
根据荷兰出院小结指南得出的13项质量标准（回复时间、患者法律状态、住院原因、他人病史、收入来源、饮酒情况、药物使用情况、体格检查结果、治疗方法、结构性诊断、DSM-III-R诊断、字数、精神科医生签名）对420份医院出院小结进行检查。
出院小结未及时送达后续护理人员手中。小结长度通常在1050字以内。一些形式标准，如根据DSM-III-R分类和签名大多符合要求（分别在67.1%和90.9%的小结中）。其他重要信息（如他人病史（24.8%）、收入来源（23.1%）、饮酒（24%）或药物使用情况（14.7%）以及如何护理患者（8%））提及不足。
荷兰社区精神卫生诊所的医院出院小结质量不足。充分的信息交流对于确保为精神科患者提供良好护理至关重要。因此，非常有必要提高医院出院小结的质量。
