Titre : Comptes-rendus de sortie des patients

Comptes-rendus de sortie des patients : Questions médicales fréquentes

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"Symptômes", "headline": "Symptômes sur Comptes-rendus de sortie des patients", "description": "Quels symptômes sont souvent mentionnés ?\nComment les symptômes sont-ils évalués ?\nLes symptômes changent-ils après le traitement ?\nLes symptômes sont-ils classés par gravité ?\nComment les symptômes influencent-ils le suivi ?", "url": "https://questionsmedicales.fr/mesh/D063886?page=3#section-symptômes" }, { "@type": "MedicalWebPage", "name": "Prévention", "headline": "Prévention sur Comptes-rendus de sortie des patients", "description": "Quelles mesures préventives sont recommandées ?\nComment la prévention est-elle abordée dans le rapport ?\nLa prévention est-elle personnalisée ?\nQuels conseils de prévention sont souvent inclus ?\nLa prévention est-elle suivie après la sortie ?", "url": "https://questionsmedicales.fr/mesh/D063886?page=3#section-prévention" }, { "@type": "MedicalWebPage", "name": "Traitements", "headline": "Traitements sur Comptes-rendus de sortie des patients", "description": "Quels types de traitements sont documentés ?\nComment les traitements sont-ils justifiés ?\nLes traitements sont-ils suivis d'effets secondaires ?\nComment les traitements sont-ils planifiés ?\nLes traitements sont-ils adaptés après la sortie ?", "url": "https://questionsmedicales.fr/mesh/D063886?page=3#section-traitements" }, { "@type": "MedicalWebPage", "name": "Complications", "headline": "Complications sur Comptes-rendus de sortie des patients", "description": "Quelles complications peuvent survenir après la sortie ?\nComment les complications sont-elles signalées ?\nLes complications sont-elles documentées dans le rapport ?\nComment prévenir les complications après la sortie ?\nLes complications influencent-elles le suivi ?", "url": "https://questionsmedicales.fr/mesh/D063886?page=3#section-complications" }, { "@type": "MedicalWebPage", "name": "Facteurs de risque", "headline": "Facteurs de risque sur Comptes-rendus de sortie des patients", "description": "Quels facteurs de risque sont souvent identifiés ?\nComment les facteurs de risque sont-ils évalués ?\nLes facteurs de risque influencent-ils le traitement ?\nLes facteurs de risque sont-ils notés dans le compte-rendu ?\nComment réduire les facteurs de risque après la sortie ?", "url": "https://questionsmedicales.fr/mesh/D063886?page=3#section-facteurs de risque" } ] }, { "@type": "FAQPage", "mainEntity": [ { "@type": "Question", "name": "Quels diagnostics sont souvent notés dans un compte-rendu ?", "position": 1, "acceptedAnswer": { "@type": "Answer", "text": "Les diagnostics incluent des maladies aiguës, chroniques et des complications post-opératoires." } }, { "@type": "Question", "name": "Comment le diagnostic est-il confirmé dans le rapport ?", "position": 2, "acceptedAnswer": { "@type": "Answer", "text": "Le diagnostic est confirmé par des examens cliniques, des tests de laboratoire et des imageries." } }, { "@type": "Question", "name": "Quelle est l'importance du diagnostic dans le compte-rendu ?", "position": 3, "acceptedAnswer": { "@type": "Answer", "text": "Il guide le suivi médical et les traitements à administrer après la sortie." } }, { "@type": "Question", "name": "Les diagnostics sont-ils classés dans le compte-rendu ?", "position": 4, "acceptedAnswer": { "@type": "Answer", "text": "Oui, ils sont souvent classés par ordre de gravité ou de chronologie." } }, { "@type": "Question", "name": "Comment les diagnostics influencent-ils le traitement ?", "position": 5, "acceptedAnswer": { "@type": "Answer", "text": "Ils déterminent les protocoles de traitement et les médicaments prescrits." } }, { "@type": "Question", "name": "Quels symptômes sont souvent mentionnés ?", "position": 6, "acceptedAnswer": { "@type": "Answer", "text": "Les symptômes incluent douleur, fièvre, fatigue et autres signes cliniques pertinents." } }, { "@type": "Question", "name": "Comment les symptômes sont-ils évalués ?", "position": 7, "acceptedAnswer": { "@type": "Answer", "text": "Ils sont évalués par l'examen physique et les antécédents médicaux du patient." } }, { "@type": "Question", "name": "Les symptômes changent-ils après le traitement ?", "position": 8, "acceptedAnswer": { "@type": "Answer", "text": "Oui, le compte-rendu note souvent l'évolution des symptômes post-traitement." } }, { "@type": "Question", "name": "Les symptômes sont-ils classés par gravité ?", "position": 9, "acceptedAnswer": { "@type": "Answer", "text": "Oui, ils peuvent être classés en fonction de leur impact sur la santé du patient." } }, { "@type": "Question", "name": "Comment les symptômes influencent-ils le suivi ?", "position": 10, "acceptedAnswer": { "@type": "Answer", "text": "Ils orientent les recommandations de suivi et les consultations nécessaires." } }, { "@type": "Question", "name": "Quelles mesures préventives sont recommandées ?", "position": 11, "acceptedAnswer": { "@type": "Answer", "text": "Les mesures incluent vaccinations, conseils diététiques et exercices physiques." } }, { "@type": "Question", "name": "Comment la prévention est-elle abordée dans le rapport ?", "position": 12, "acceptedAnswer": { "@type": "Answer", "text": "Elle est abordée par des recommandations spécifiques basées sur le diagnostic." } }, { "@type": "Question", "name": "La prévention est-elle personnalisée ?", "position": 13, "acceptedAnswer": { "@type": "Answer", "text": "Oui, elle est souvent adaptée aux antécédents médicaux et au mode de vie du patient." } }, { "@type": "Question", "name": "Quels conseils de prévention sont souvent inclus ?", "position": 14, "acceptedAnswer": { "@type": "Answer", "text": "Des conseils sur l'alimentation, l'exercice et l'arrêt du tabac sont fréquents." } }, { "@type": "Question", "name": "La prévention est-elle suivie après la sortie ?", "position": 15, "acceptedAnswer": { "@type": "Answer", "text": "Oui, le suivi des mesures préventives est souvent recommandé lors des consultations." } }, { "@type": "Question", "name": "Quels types de traitements sont documentés ?", "position": 16, "acceptedAnswer": { "@type": "Answer", "text": "Les traitements incluent médications, interventions chirurgicales et thérapies physiques." } }, { "@type": "Question", "name": "Comment les traitements sont-ils justifiés ?", "position": 17, "acceptedAnswer": { "@type": "Answer", "text": "Ils sont justifiés par les diagnostics et l'évolution des symptômes du patient." } }, { "@type": "Question", "name": "Les traitements sont-ils suivis d'effets secondaires ?", "position": 18, "acceptedAnswer": { "@type": "Answer", "text": "Oui, les effets secondaires potentiels sont souvent notés pour chaque traitement." } }, { "@type": "Question", "name": "Comment les traitements sont-ils planifiés ?", "position": 19, "acceptedAnswer": { "@type": "Answer", "text": "Ils sont planifiés en fonction des besoins individuels et des protocoles médicaux." } }, { "@type": "Question", "name": "Les traitements sont-ils adaptés après la sortie ?", "position": 20, "acceptedAnswer": { "@type": "Answer", "text": "Oui, des ajustements peuvent être nécessaires en fonction de l'évolution du patient." } }, { "@type": "Question", "name": "Quelles complications peuvent survenir après la sortie ?", "position": 21, "acceptedAnswer": { "@type": "Answer", "text": "Les complications incluent infections, douleurs persistantes et complications liées aux traitements." } }, { "@type": "Question", "name": "Comment les complications sont-elles signalées ?", "position": 22, "acceptedAnswer": { "@type": "Answer", "text": "Elles sont signalées par des observations cliniques et des tests de suivi." } }, { "@type": "Question", "name": "Les complications sont-elles documentées dans le rapport ?", "position": 23, "acceptedAnswer": { "@type": "Answer", "text": "Oui, elles sont souvent documentées pour informer le suivi médical." } }, { "@type": "Question", "name": "Comment prévenir les complications après la sortie ?", "position": 24, "acceptedAnswer": { "@type": "Answer", "text": "La prévention passe par des soins appropriés et le respect des recommandations médicales." } }, { "@type": "Question", "name": "Les complications influencent-elles le suivi ?", "position": 25, "acceptedAnswer": { "@type": "Answer", "text": "Oui, elles peuvent nécessiter des consultations supplémentaires et des ajustements de traitement." } }, { "@type": "Question", "name": "Quels facteurs de risque sont souvent identifiés ?", "position": 26, "acceptedAnswer": { "@type": "Answer", "text": "Les facteurs incluent l'âge, les antécédents familiaux et les habitudes de vie." } }, { "@type": "Question", "name": "Comment les facteurs de risque sont-ils évalués ?", "position": 27, "acceptedAnswer": { "@type": "Answer", "text": "Ils sont évalués par l'anamnèse et des tests de dépistage spécifiques." } }, { "@type": "Question", "name": "Les facteurs de risque influencent-ils le traitement ?", "position": 28, "acceptedAnswer": { "@type": "Answer", "text": "Oui, ils peuvent orienter les choix thérapeutiques et les recommandations de suivi." } }, { "@type": "Question", "name": "Les facteurs de risque sont-ils notés dans le compte-rendu ?", "position": 29, "acceptedAnswer": { "@type": "Answer", "text": "Oui, ils sont souvent notés pour une meilleure gestion des soins futurs." } }, { "@type": "Question", "name": "Comment réduire les facteurs de risque après la sortie ?", "position": 30, "acceptedAnswer": { "@type": "Answer", "text": "La réduction passe par des changements de mode de vie et un suivi médical régulier." } } ] } ] }

Sources (10000 au total)

Hospital Discharge Summaries Are Insufficient Following ICU Stays: A Qualitative Study.

Primary care providers (PCPs) receive limited information about their patients' ICU stays; we sought to understand what additional information PCPs desire to support patients' recovery following criti... Semistructured interviews with PCPs conducted between September 2020 and April 2021.... Academic health system with central quaternary-care hospital and associated Veterans Affairs medical center.... Fourteen attending internal medicine or family medicine physicians working in seven clinics across Southeast Michigan (median, 10.5 yr in practice).... We analyzed using a modified Rigorous and Accelerated Data Reduction (RADaR) technique to identify gaps in current discharge summaries for patients with ICU stays, impacts of these gaps, and desired I... PCPs reported receiving limited ICU-specific information in hospital discharge summaries. PCPs often spent significant time reading inpatient records for additional information. Information desired in... Our results identified key data elements sought by PCPs about patients' ICU stays and suggest opportunities to improve care through developing tools/templates to provide PCPs with ICU-specific informa...

Transforming healthcare documentation: Harnessing the potential of AI to generate discharge summaries.

Hospital discharge summaries play an essential role in informing GPs of recent admissions to ensure excellent continuity of care and prevent adverse events, however, they are notoriously poorly writte... To evaluate the potential of AI to produce high-quality discharge summaries equivalent to the level of a doctor who has completed the UK Foundation Programme.... Feasibility study using 25 mock patient vignettes.... Using the 25 mock patient vignettes, 25 ChatGPT and 25 junior doctor written discharge summaries were generated. Quality and suitability was determined through both independent GP evaluators and adher... Of the 25 AI written discharge summaries 100% were deemed by GPs to be of an acceptable quality compared to that of 92% for the junior doctor summaries. They both showed a mean compliance of 97% with ... AI has proven to produce discharge summaries of equivalent quality as a doctor who has completed the UK Foundation Programme, however, larger studies with real-world patient data with NHS-approved AI ...

Evaluating Large Language Models for Drafting Emergency Department Discharge Summaries.

Large language models (LLMs) possess a range of capabilities which may be applied to the clinical domain, including text summarization. As ambient artificial intelligence scribes and other LLM-based t... To investigate the performance of GPT-4 and GPT-3.5-turbo in generating Emergency Department (ED) discharge summaries and evaluate the prevalence and type of errors across each section of the discharg... Cross-sectional study.... University of California, San Francisco ED.... We identified all adult ED visits from 2012 to 2023 with an ED clinician note. We randomly selected a sample of 100 ED visits for GPT-summarization.... We investigate the potential of two state-of-the-art LLMs, GPT-4 and GPT-3.5-turbo, to summarize the full ED clinician note into a discharge summary.... GPT-3.5-turbo and GPT-4-generated discharge summaries were evaluated by two independent Emergency Medicine physician reviewers across three evaluation criteria: 1) Inaccuracy of GPT-summarized informa... From 202,059 eligible ED visits, we randomly sampled 100 for GPT-generated summarization and then expert-driven evaluation. In total, 33% of summaries generated by GPT-4 and 10% of those generated by ... In this cross-sectional study of 100 ED encounters, we found that LLMs could generate accurate discharge summaries, but were liable to hallucination and omission of clinically relevant information. A ...

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

The transition from hospital inpatient care to medical care in the community is a high-risk period for adverse events. Inadequate communication, including low-quality or unavailable discharge summarie... To assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GP), and the interpretation of these abbreviations by GP and hospital-based junior... This is a retrospective audit of 802 discharge summaries completed during a 1-week period in 2017 by a Queensland regional health service. GP and local junior doctors then attempted interpretation of ... A total of 99% (794) discharge summaries included abbreviations. A total of 1612 different abbreviations was used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (... Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation....

Leveraging artificial intelligence in neurosurgery-unveiling ChatGPT for neurosurgical discharge summaries and operative reports.

Chat generative pre-trained transformer (GPT) is a novel large pre-trained natural language processing software that can enable scientific writing amongst a litany of other features. Given this, there... We investigated the time taken for the composition of neurosurgical discharge summaries and operative reports at a major University hospital. In so doing, we compared currently employed speech recogni... The composition of neurosurgical discharge summaries and operative reports with the assistance of ChatGPT leads to a statistically significant time reduction across all three diseases/report types: p ... ChatGPT assisted in the writing of discharge summaries and operative reports as evidenced by an impressive reduction in time spent as compared to standard speech recognition software. While promising,...

A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care.

Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and... Multiple baseline trial with randomized and staggered implementation.... Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city.... Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019.... A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system.... We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post impl... Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward....

[Quality of medication documentation in patientś discharge summaries after implementing new legal requirements].

Discharge from hospital is a risk to drug continuity and medication safety. In Germany, new legal requirements concerning the management of patient discharge from the hospital came into force in 2017.... Within the scope of an explorative retrospective observational study, the minimum requirements were operationalized and a second set of assessment criteria was derived from the recommendation "Good Pr... In total, 11 quality criteria were derived from the minimum requirements. According to the eligibility criteria (i. e., three or more discharge medications) 352 discharge summaries (42 wards; issued i... To date, the wording of the German legal requirements allows for different interpretations without considering the respective clinical setting and the medication actually prescribed. For future clarif...

Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals.

Patient experience when transitioning home from hospital is an important quality metric linked to improved patient outcomes. We evaluated the impact of a hospital-based care transition intervention, p... We used a repeated cross-sectional study design to compare yearly positive (top-box) responses to four questions centered on discharge communication from the Canadian Patient Experience Survey (2016-2... 512,288 individual responses were included. Compared to non-implementation hospitals, hospitals with full implementation (>50% discharges) reported higher odds for having discussed the help needed whe... PODS implementation was associated with higher odds of positive patient experience, particularly for questions focused on discharge planning. Further efforts should center on discharge management, spe...