出院总结和患者用药变化的核对

L. Piggott
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引用次数: 0

摘要

家庭医生会定期接待住院的病人。出院时,这些患者中的许多人可能会改变药物,需要他们的家庭医生的注意,要么开始新的重复处方,要么修改以前的处方。这一行动应该清楚地记录下来,这样就可以很容易地识别出已经审查了出院摘要。本研究着眼于采取的行动和编码相关的医院出院总结在英国的一般做法。这种做法在正确更改药物方面非常准确和安全,但记录和编码出院总结的比率很低,出院总结已被审查并按要求采取行动。建议制定统一的守则,并要求在实习医生和培训医生的培训材料中包含与出院摘要有关的文件。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Reconciliation of hospital discharge summaries and changes in patient medications
Family doctors will regularly have patients who are admitted to hospital. On discharge, many of these patients may have alterations to the medications that require attention by their family doctor, to either start a new repeat prescription or amend previous ones. This action should be clearly documented, so it can be recognised easily that the discharge summary has been reviewed. This study looks at the action taken and coding related to hospital discharge summaries in a general practice in the United Kingdom. The practice was very accurate and safe in making correct changes to medications but had low rates of documenting and coding that the discharge summary has been reviewed and actioned as required. A uniform code was recommended, and required documentation related to discharge summaries included in the practice’s training materials for locum and training doctors.
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