Christensen K A, Mainz J, Kristensen E
Silkeborg Centralsygehus, medicinsk afdeling.
Ugeskr Laeger. 1997 Nov 24;159(48):7141-5.
The aim of this study was to evaluate the informative content of referrals and discharge summary letters concerning patients admitted acutely to the Department of Internal Medicine in a Danish district hospital, and to estimate the delivery time for discharge summary letters. A total of 132 patients were consecutively enrolled from May 2nd to May 30th 1995. The receiving doctor in the hospital on the day of admission as well as the general practitioner who received the discharge summary letter were asked to complete a specific designed questionnaire. The referrals were often insufficient regarding patient history (in particular data on psychosocial aspects and prescribed medicine) and physical examination. Every fifth referral was never received by the hospital. The delivery time for discharge summary letters was 13 days (0-87 days). In every fifth case the information was needed earlier. The discharge summary letters often lacked information concerning what the patients had been told, prognosis and suggestions concerning social medicine. This study indicates that the collaboration between general practitioners and doctors in hospital can be improved by of enhancing the informative content of referrals and discharge summary letters and the expedition time of discharge summary letters.
本研究旨在评估丹麦一家地区医院内科急性收治患者的转诊信和出院小结信的信息内容,并估计出院小结信的送达时间。1995年5月2日至5月30日,共连续纳入132例患者。要求入院当天医院的接收医生以及收到出院小结信的全科医生填写一份专门设计的问卷。转诊信在患者病史(特别是心理社会方面的数据和所开药物)和体格检查方面往往不够充分。每五封转诊信中就有一封医院从未收到。出院小结信的送达时间为13天(0 - 87天)。每五例中就有一例需要更早获得信息。出院小结信往往缺乏关于告知患者的内容、预后以及社会医学建议的信息。本研究表明,通过提高转诊信和出院小结信的信息内容以及出院小结信的送达速度,可以改善全科医生与医院医生之间的协作。