初级医生对出院过程的看法:一项探讨出院摘要准备与药物和解的质性研究。

Christina Meligonis, Laetitia Hattingh, Sean Alcorn
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引用次数: 0

摘要

背景:出院是一个脆弱的点在病人的旅程中增加药物相关的错误发生。尽管出院摘要作为医院-社区医疗界面的沟通工具很重要,但许多因素阻碍了医生准备准确及时的出院摘要和药物清单的能力。目的:探讨初级医生对出院过程的认知。方法:于2022年11月至12月,对某城市卫生服务机构的初级医生(实习生、住院医师和注册医师)进行半结构化访谈。访谈工具包含提示,以探索与出院过程有关的意见和经验,特别是出院摘要、药物和解和医疗保健专业人员之间的协作。访谈记录按主题进行分析。结果:对20名初级医生进行了访谈。五个相互关联的主题出现了:(1)工作量和时间限制,(2)对药物和解的看法,(3)与药剂师的合作,(4)卫生保健专业人员之间的沟通,以及(5)组织因素的影响。准备出院总结的主要障碍包括时间压力和高病人流动率。帮助医生的因素包括直接参与病人的护理,指定时间完成出院总结,记录良好的住院病人进展记录,以及药剂师记录的综合住院药物信息的可用性。结论:初级医生在出院过程中面临着重大挑战。在工作量大、病人流动率高的情况下,护理的连续性可能会受到影响,因为直接的病人护理任务优先于准备出院摘要。对卫生信息管理实践的影响:研究结果强调需要加强对初级医生的医学教育和支持,同时改进药师专业知识的整合,以促进清晰、准确和及时的出院记录。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Junior doctors' perspectives on the hospital discharge process: A qualitative study exploring preparation of discharge summaries and medication reconciliation.

Background: Hospital discharge is a vulnerable point in a patient's journey where increased medication-related errors occur. Despite the importance of discharge summaries as a communication tool at the hospital-community healthcare interface, many factors impede doctors' ability to prepare accurate and timely discharge summaries and medication lists. Objective: To explore junior doctors' perceptions of the hospital discharge process. Method: Semi-structured interviews were conducted with purposively selected junior doctors (interns, residents and registrars) from a metropolitan health service between November and December 2022. The interview tool contained prompts to explore opinions and experiences relating to the discharge processes, specifically discharge summaries, medication reconciliation and collaboration between healthcare professionals. Interview transcriptions were thematically analysed. Results: Twenty junior doctors were interviewed. Five interconnected themes emerged: (1) workload and time restraints, (2) perceptions of medication reconciliation, (3) collaboration with pharmacists, (4) communication between healthcare professionals and (5) impact of organisational factors. Significant barriers to preparing discharge summaries included time pressures and high patient turnover. Factors aiding doctors included direct involvement in the patient's care, designated time to complete discharge summaries, well-documented in-patient progress notes and availability of comprehensive admission medication information recorded by pharmacists. Conclusion: Junior doctors face significant challenges during the hospital discharge process. Under heavy workloads and high patient turnover, continuity of care can be compromised as direct patient care tasks take priority over preparing discharge summaries. Implications for health information management practice: The findings underscore the need for enhanced medicines education and support for junior doctors, alongside improved integration of pharmacist expertise, to facilitate clear, accurate and timely discharge documentation.

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