Comptes-rendus de sortie des patients : Questions médicales fréquentes
Nom anglais: Patient Discharge Summaries
Descriptor UI:D063886
Tree Number:N06.850.520.308.940.968.750
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"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 ?",
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"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 ?",
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"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 ?",
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"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 ?",
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"name": "Quels diagnostics sont souvent notés dans un compte-rendu ?",
"position": 1,
"acceptedAnswer": {
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"text": "Les diagnostics incluent des maladies aiguës, chroniques et des complications post-opératoires."
}
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{
"@type": "Question",
"name": "Comment le diagnostic est-il confirmé dans le rapport ?",
"position": 2,
"acceptedAnswer": {
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"text": "Le diagnostic est confirmé par des examens cliniques, des tests de laboratoire et des imageries."
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"@type": "Question",
"name": "Quelle est l'importance du diagnostic dans le compte-rendu ?",
"position": 3,
"acceptedAnswer": {
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"text": "Il guide le suivi médical et les traitements à administrer après la sortie."
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{
"@type": "Question",
"name": "Les diagnostics sont-ils classés dans le compte-rendu ?",
"position": 4,
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"text": "Oui, ils sont souvent classés par ordre de gravité ou de chronologie."
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{
"@type": "Question",
"name": "Comment les diagnostics influencent-ils le traitement ?",
"position": 5,
"acceptedAnswer": {
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"text": "Ils déterminent les protocoles de traitement et les médicaments prescrits."
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{
"@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."
}
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{
"@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."
}
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{
"@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."
}
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{
"@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."
}
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{
"@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."
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{
"@type": "Question",
"name": "Quelles mesures préventives sont recommandées ?",
"position": 11,
"acceptedAnswer": {
"@type": "Answer",
"text": "Les mesures incluent vaccinations, conseils diététiques et exercices physiques."
}
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{
"@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."
}
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{
"@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."
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{
"@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."
}
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{
"@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."
}
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{
"@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."
}
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Background Discharge summaries (TTOs) are essential documents in the effective communication between primary and secondary care, particularly in conveying critical post-discharge instructions to patie...
Introduction Discharge summaries (DS) allow continued patient care after being discharged from the hospital. Only a few quality improvement projects (QIPs) focused on assessing and improving the quali...
Background The discharge summary is a vital component of the modern health system. It is defined as a synopsis of information regarding events occurring during the inpatient care of a patient, to allo...
Brief Hospital Course (BHC) summaries are succinct summaries of an entire hospital encounter, embedded within discharge summaries, written by senior clinicians responsible for the overall care of a pa...
Discharging intensive care unit (ICU) patients directly home is becoming more common. High-quality ICU discharge summaries are crucial in the transition of patient care. Currently, at Memorial Health ...
A single-center retrospective chart review of pediatric patients discharged directly from a 10-bed Pediatric ICU to home was conducted. Charts were evaluated pre- and post-intervention. The interventi...
Thirty-nine total patients, 13 pre-intervention and 26 post-intervention were included in the study. In the pre-intervention group, 38.5% (5/13) had discharge summaries completed in less than 48 hours...
Standardizing discharge summary templates and encouraging stricter institutional policies regarding the timely completion of discharge summaries can improve the ICU discharge process. Formal resident ...
Danish hospital physicians are obliged to mark the discharge summaries addressing whether the patient's GP is recommended to follow up, as well as to state suggested follow-up actions in a recommendat...
This study aims to investigate the GP's experiences with the recommendation text box....
A questionnaire sent to a representative sample of general practitioners in Denmark....
A questionnaire was prepared for GPs based on background material, focus group interviews and discussions with GPs and hospital physicians. It was subsequently pilot-tested by fellow researchers and G...
Almost ¾ of the general practitioners (72%) 'totally or partly agree' that the recommendation text box is easy to find. In addition, our results show significant differences between software used by t...
GPs generally find that the recommendation text box provides them with brief and precise information about the recommended follow-up. In addition, the software used by the GPs has a significant influe...
Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where E...
The application of standardized patient summaries would reduce the risk of information overload and related problems for physicians and nurses. Although the International Patient Summary (IPS) standar...
We converted clinical data from the Standardized Structured Medical Information eXchange version 2 (SS-MIX2) storage at Tohoku University Hospital into the Health Level 7 Fast Healthcare Interoperabil...
The FHIR resources of seven of the necessary IPS sections were successfully converted from existing SS-MIX2 data. In the main view of the application we developed, all the minimum necessary patient in...
We implemented a patient summary application that summarizes and visualizes patient information accumulated by existing systems and is evaluated in common use cases in Japan. Efficient sharing of the ...
Electronic Medical Records (EMRs) contain clinical narrative text that is of great potential value to medical researchers. However, this information is mixed with Personally Identifiable Information (...
Inadequate follow-up of incidental imaging findings (IIFs) can result in poor patient outcomes, patient dissatisfaction, and provider malpractice. At our institution, radiologists flag IIFs during rep...
Inpatient records with IIFs from 2018 to 2021 were retrospectively reviewed to determine type of IIFs, follow-up recommendations, and mention of IIFs on discharge summaries. Nurse coordinators spoke t...
Incidental imaging findings were reported in 51% of discharge summaries (711/1383). When nurse coordinators called patients and PCPs regarding IIFs at the time follow-up was due, the patients and PCPs...
With implementation of EHR notifications to providers regarding IIFs, IIFs were included in 51% of discharge summaries. Lack of inclusion of IIFs on discharge summaries could be related to transitions...