In order to develop a baseline information on a uniform data set, this study has tried to collect and analyze structural formats of the existing hospital discharge summaries. Data have been collected from the 56 general hospitals in metropolitan city of Seoul.
The study reveals that, though hospital discharge summary is a single and useful source of hospital information, no uniform hospital discharge summaries are in practice. Of the study hospitals, 52.6 % have used some forms of systematic discharge summary, however, 16.9 % used blank sheet form. The most common items appeared are patient identification, final diagnosis, and physician´s signature. A few hospitals include information on hospital charges.
This study has conducted a small opinion survey with the sample of 60 physicians. Most of doctors (86.7%) have responded that discharge summary is important and useful. But the level of their satisfaction is not that high. This implies the need for improvement with data set from hospital discharge summary.
In conclusion, this study has proposed the following 17 items as a basic data set for uniform hospital discharge summary: 1) Hospital No. 2) Patient No. 3) Patient identification. 4) Date of admission and discharge 5) Department of admission and discharge 6) Transfer 7) Chief complaints 8) History 9) Laboratory findings 10) Final diagnosis II) Treatment and operation 12) Prescription at the point of discharge 13) Follow-up 14) Complication 15) Results 16) Medical charges 17) Signiture.
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