Information for community hospitals.

Health bulletin Pub Date : 2002-01-01
J Urquhart, B J M Graham, A Ward, H Greig
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Abstract

Objective: To design and test a revised data collection system for routine patient based data in the Community Hospital setting in Scotland.

Design: A two part qualitative study was designed to identify the requirements for Community Hospital information, develop a data set to meet these requirements and pilot a proposed Community Hospital Information System.

Setting: Identification of the information deficit (Stage 1) involved administering face to face questionnaires in all relevant Health Board areas in Scotland; piloting of the proposed information system (Stage 2) was carried out in four Community Hospitals in Scotland.

Results: Stage 1 of the study highlighted the information requirements as including: who is being treated; why they are there; how complex their needs are; what is being done and by whom; and what is happening next. The additionally required data included: admission reason--medical/social; type of care--intended and provided; all relevant diagnoses and social factors; medication--on admission and discharge; interventions--nursing/GP/consultant; dependency throughout stay; delayed discharge information; and discharge plan. The summary of recommendations that flowed from this part of the study includes: incremental electronic record; link with GP and acute systems; interface with other community systems; duplication of recording; accessibility at local level with variable levels of access (to protect patient confidentiality). Stage 2 of the study piloted the collection of the proposed dataset and permitted development of suitable feedback information, in particular the patient summary screens. Economic evaluation of the proposed dataset compared to the existing data was carried out in parallel with the study and is reported elsewhere.

Conclusion: It is feasible and highly desirable to collect clinically useful information at little additional cost and to provide relevant feedback, including useful patient summary screens, representing the patient stay in hospital.

社区医院信息。
目的:设计和测试一种改进的数据收集系统,用于苏格兰社区医院的常规患者数据。设计:设计了两部分的定性研究,以确定社区医院信息的需求,开发满足这些需求的数据集,并试点拟议的社区医院信息系统。背景:查明信息不足(第一阶段)涉及在苏格兰卫生局所有相关领域进行面对面的问卷调查;拟议的信息系统试点(第二阶段)在苏格兰的四家社区医院进行。结果:研究的第一阶段强调了信息要求,包括:谁正在接受治疗;他们为什么在那里;他们的需求有多复杂;正在做什么,由谁来做;接下来会发生什么呢?额外需要的数据包括:入院原因——医疗/社会;护理类型——预期的和提供的;所有相关诊断和社会因素;药物治疗——入院和出院时;干预措施——护士/医生/顾问;整个逗留期间的依赖;延迟放电信息;以及出院计划。从这部分研究中得出的建议总结包括:增量电子记录;与普通GP和急性系统连接;与其他社区系统衔接;重复记录;可访问性在地方层面上具有不同的访问级别(以保护患者的机密性)。该研究的第二阶段试点了拟议数据集的收集,并允许开发适当的反馈信息,特别是患者总结筛选。与现有数据相比,拟议数据集的经济评估与研究同时进行,并在其他地方报告。结论:以很少的额外费用收集临床有用的信息并提供相关的反馈是可行的,也是非常可取的,包括有用的患者总结屏幕,代表患者的住院时间。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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