门诊信笺:要求及内容。

Effective health care Pub Date : 1985-01-01
D W Young, J Parkes, W A Davis, D Harman, R S Williams
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引用次数: 0

摘要

对25名全科医生就门诊信件内容进行了访谈。人们普遍同意需要以下信息:诊断、异常的身体检查结果、异常的常规和非常规检查结果、治疗的变化、对患者身体状况的评论和处置。分析215封门诊信件的内容,并与全科医生的意见进行比较。来自内科和外科诊所的信件几乎没有什么不同。两者在报告异常检测结果、调查的原因和意义以及向患者提供详细信息方面都存在一定程度的缺陷。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Out-patient letters: requirement and contents.

Twenty-five general practitioners were interviewed about the contents of out-patient letters. There was universal agreement on the need for the following information: diagnosis, abnormal physical findings, abnormal routine and non-routine test results, changes in treatment, comments on the patient's physical condition and disposal. The contents of 215 out-patient letters were analysed and the results compared with the GPs' views. There was little difference in the letters from medical and surgical clinics. Both were deficient to a limited extent in the reporting of abnormal test results, the reasons for, and significance of investigations, and in detailing the information given to patients.

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