Creating a Better Discharge Summary: Improvement in Quality and Timeliness Using an Electronic Discharge Summary
Creating a Better Discharge Summary: Improvement in Quality and Timeliness Using an Electronic Discharge Summary
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DOI：
10.1002/jhm.425
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发表时间：
2009-04-01
影响因子：
2.6
通讯作者：
Baker, David W.
中科院分区：
文献类型：
--
作者：
O'Leary, Kevin J.;Liebovitz, David M.;Baker, David W.
背景技术背景：在住院和门诊医生之间的信息传递的缺陷是常见的和潜在的dangerous.Objective：评估效果的一个新创建的电子discharge summary.Design AND Participants：前后评价出院摘要使用调查门诊医生和病历review.MEASUREMENTS：使用5分制李克特量表对实施电子出院总结前后门诊医生对出院总结的满意度进行评级（1 =非常不满意; 5 =非常满意）。此外，196个随机选择的出院摘要实施前和实施后的及时性和存在的16个关键内容areas by 3 internists.RESULTS：二百二十六416（54%）和256 397（64%）门诊医生完成了基线和postimplementation调查。使用电子出院小结后，对出院小结质量和及时性的满意度提高（平均质量评分3.04比3.64; P < 0.001，平均及时性评分2.59比3.34; P < 0.001）。出院后3天内完成电子出院小结的比例高于口述出院小结（44.8% vs 74.1%; P < 0.001）。出院总结的几个要素更常与电子出院总结一起出现，包括随访问题的讨论（52.0% vs 75.8%; P = 0.001），待检测结果（13.9%对46.3%; P < 0.001），并向患者和/或家属提供信息（85.1%对95.8%; P = 0.01）。结论：使用电子出院小结显著提高了出院小结的质量和及时性。医院医学杂志2009;4：219-225。(C)2009年医院医学会。
BACKGROUND: Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous.OBJECTIVE: TO evaluate the effect of a newly-created electronic discharge summary.DESIGN AND PARTICIPANTS: Pre-post evaluation of discharge summaries using a Survey Of Outpatient physicians and a medical records review.MEASUREMENTS: Outpatient physicians' ratings of satisfaction with discharge Summaries before and after implementation of an electronic discharge Summary using a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied). Additionally, 196 randomly selected discharge summaries before and after implementation were rated for timeliness and presence of 16 key content areas by 3 internists.RESULTS: Two hundred and twenty-six of 416 (54%) and 256 of 397 (64%) outpatient physicians completed the baseline and postimplementation surveys. Satisfaction with quality and timeliness of discharge summaries improved with the use of the electronic discharge summary (mean quality rating 3.04 versus 3.64; P < 0.001, mean timeliness rating 2.59 versus 3.34; P < 0.001). A higher percentage of electronic discharge summaries were completed within 3 days of discharge as compared with dictated discharge summaries (44.8% versus 74.1%; P < 0.001). Several elements of the discharge Summary were present more often with the electronic discharge summary, including discussion of follow-up issues (52.0% Versus 75.8%; P = 0.001), pending test results (13.9% versus 46.3%; P < 0.001), and information provided to the patient and/or family (85.1% versus 95.8%; P = 0.01).CONCLUSIONS: The use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. journal of Hospital Medicine 2009;4:219-225. (C) 2009 Society of Hospital Medicine.