Aziz M M, Corder A P
County Hospital, Hereford.
Ann R Coll Surg Engl. 1996 Jul;78(4 Suppl):183-5.
A one-year audit of operation lists and discharge summaries of one surgical firm showed only 1.4 percent of operation lists contained errors or omissions and only 5 percent contained abbreviations. 74.2 percent of discharge summaries were dictated within one week of discharge. A high proportion of day cases allowed 44.7 percent of the discharge summaries to be dictated on the day of operation. Close consultant and secretarial involvement in the preparation of operating lists can ensure a high degree of accuracy. Day case operation notes should be combined with a discharge letter to optimise communication with general practitioners.
对一家外科公司的手术清单和出院小结进行的为期一年的审计显示，只有1.4%的手术清单存在错误或遗漏，只有5%包含缩写。74.2%的出院小结在出院后一周内完成口述。很大一部分日间手术病例使得44.7%的出院小结能够在手术当天完成口述。密切的会诊医生和秘书参与手术清单的准备工作可以确保高度的准确性。日间手术记录应与出院信相结合，以优化与全科医生的沟通。
