Consenso para la elaboración del informe de alta hospitalaria en especialidades médicas

Gutiérrez, Pedro Conthe; Alegría, Javier García; Farriols, Ramon Pujol; Alfageme, Inmaculada; Menéndez, Sara Artola; Barba, Raquel; Garzón, Pedro Javier Cañones; Pérez, Paloma Casado; Moreno, Fernando de Álvaro; Royo, Luis Escosa; Fernández, Albert J. Jovell; Gil, Cristóbal León; Gil, Arturo Lisbona; Vázquez, Raúl Márquez; Rodríguez-Moñino, Ana Pastor; Martínez, David A. Pérez

doi:10.1016/j.medcli.2009.12.002

Cited by 41 publications

(2 citation statements)

References 13 publications

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“…The study identified, however, that general recommendations concerning a healthy life-style, such as detailed instructions on how to stop smoking, how to improve nutrition or undertake more daily physical activity, or the provision of information concerning the advantages of influenza and pneumococcal vaccination, were often not provided. This issue has been recently audited and specific national recommendations have been issued [30], [31].…”

Section: Discussionmentioning

confidence: 99%

Clinical Audit of COPD Patients Requiring Hospital Admissions in Spain: AUDIPOC Study

et al. 2012

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BackgroundsAUDIPOC is a nationwide clinical audit that describes the characteristics, interventions and outcomes of patients admitted to Spanish hospitals because of an exacerbation of chronic obstructive pulmonary disease (ECOPD), assessing the compliance of these parameters with current international guidelines. The present study describes hospital resources, hospital factors related to case recruitment variability, patients’ characteristics, and adherence to guidelines.Methodology/Principal FindingsAn organisational database was completed by all participant hospitals recording resources and organisation. Over an 8-week period 11,564 consecutive ECOPD admissions to 129 Spanish hospitals covering 70% of the Spanish population were prospectively identified. At hospital discharge, 5,178 patients (45% of eligible) were finally included, and thus constituted the audited population. Audited patients were reassessed 90 days after admission for survival and readmission rates. A wide variability was observed in relation to most variables, hospital adherence to guidelines, and readmissions and death. Median inpatient mortality was 5% (across-hospital range 0–35%). Among discharged patients, 37% required readmission (0–62%) and 6.5% died (0–35%). The overall mortality rate was 11.6% (0–50%). Hospital size and complexity and aspects related to hospital COPD awareness were significantly associated with case recruitment. Clinical management most often complied with diagnosis and treatment recommendations but rarely (<50%) addressed guidance on healthy life-styles.Conclusions/SignificanceThe AUDIPOC study highlights the large across-hospital variability in resources and organization of hospitals, patient characteristics, process of care, and outcomes. The study also identifies resources and organizational characteristics associated with the admission of COPD cases, as well as aspects of daily clinical care amenable to improvement.

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Section: Discussionmentioning

confidence: 99%

Clinical Audit of COPD Patients Requiring Hospital Admissions in Spain: AUDIPOC Study

et al. 2012

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“…El 2005, el Collegi de Metges de Barcelona va editar (dintre de la collecció Quaderns de la Bona Praxi) un fulletó molt interessant anomenat Informes clínics, eines de comunicació, en el qual es plantegen unes reflexions i es fan unes recomanacions sobre quin hauria de ser el contingut i l'estil d'aquests escrits. En diversos treballs publicats (Conthe Gutiérrez et al 2010;Medicina Clínica. Manual de estilo, 1993;Mestres et al 1995) es fan propostes sobre l'estructura i el contingut dels informes mèdics i dels escrits en general.…”

Section: E L V O C a B U L A R I D E L S M E T G E Sunclassified