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Communication with general practitioners after accident and emergency attendance: computer generated letters are often deficient

机译:事故和紧急情况出诊后与全科医生沟通:计算机生成的信函通常不足

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摘要

>Methods: Retrospective review of 300 discharge letters and case notes. >Results: 29% of all computer generated discharge information was incomplete or misleading. Twenty five per cent of all correspondence was lacking or unacceptable overall. The principal reasons for substandard correspondence were inaccurate coding of diagnoses and procedures, and failure to include specific information relevant to patients' follow up. >Conclusions: Computer generated discharge communication is often deficient. Staff using such systems should be made aware of the importance of accurate coding, and use added explanatory text to clarify diagnoses, management, and follow up as required.
机译:>方法:回顾性分析300份出院信和案例记录。 >结果:所有计算机生成的放电信息中有29%不完整或具有误导性。总体而言,所有信件中有25%缺乏或不可接受。符合标准不符的主要原因是诊断和程序的编码不正确,以及未能包括与患者随访有关的特定信息。 >结论:计算机生成的放电通讯经常不足。使用这种系统的工作人员应了解准确编码的重要性,并使用添加的解释性文字来明确诊断,管理和跟进要求。

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