目的：调查护士使用转诊信和出院总结的方式，以及他们认为这些文件的质量对安全有效的实践很有价值。
方法：本研究包括定性，使用方便抽样在建构主义范式中进行案例研究设计。
方法：对护士进行了访谈，以调查他们与转诊信和出院总结有关的做法。数据收集还涉及护士的检查和评估，包括通过焦点小组会议从两家澳大利亚医院的病历中获得的10封转诊信和出院摘要。对数据进行转录和感应分析。
结果：总而言之，67名护士参加了访谈或焦点小组。护士表示，他们在住院期间的不同时间照顾患者时，会使用转诊信和出院摘要来告知他们的工作。这些文件协助他们进行口头交接，使他们能够教育病人他们的病情和治疗，并提供高标准的护理。他们最重视的推荐信和出院摘要的质量是语言和交流，对受众和临床知识的认识，以及平衡信息的简洁性和全面性。
结论：护士依靠转诊信和出院总结来确保安全和有效的患者护理。他们用这些文件来加强他们的口头交接，有助于患者护理，并教育患者关于他们的病情和治疗。他们确定了这些文件的几种质量，以帮助他们维护患者安全，包括信息的清晰度和简洁性。
■重要的是要写清楚推荐信和出院摘要，简洁而全面，因为护士将其用作计划和提供护理的关键证据来源，并与其他卫生专业人员沟通，传达护理目标和实施治疗计划。
结论：护士报告说，他们定期使用转诊信和出院总结作为患者住院期间的宝贵证据来源。他们最重视的这些文件的质量是语言和沟通风格，受众和临床知识的意识，以及平衡信息的简洁性和全面性。这项研究在鼓励有效的转诊信和出院总结写作方面对患者体验具有重要影响。
■我们通过SRQR报告方法遵守了相关的EQUATOR准则。
■没有患者或公众捐款。
OBJECTIVE: To investigate the ways that nurses engage with referral letters and discharge summaries, and the qualities of these documents they find valuable for safe and effective practice.
METHODS: This
study comprised a qualitative, case-
study design within a constructivist paradigm using convenience sampling.
METHODS: Interviews were conducted with nurses to investigate their practices relating to referral letters and discharge summaries. Data collection also involved nurses\' examination and evaluation of a diverse range of 10 referral letters and discharge summaries from medical records at two Australian hospitals through focus-group sessions. The data were transcribed and analysed inductively.
RESULTS: In all, 67 nurses participated in interviews or focus groups. Nurses indicated they used referral letters and discharge summaries to inform their work when caring for patients at different times throughout their hospitalisation. These documents assisted them with verbal handovers, to enable them to educate patients about their condition and treatment and to provide a high standard of care. The qualities of referral letters and discharge summaries that they most valued were language and communication, an awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information.
CONCLUSIONS: Nurses relied on referral letters and discharge summaries to ensure safe and effective patient care. They used these documents to enhance their verbal handovers, contribute to patient care and to educate the patient about their condition and treatment. They identified several qualities of these documents that assisted them in maintaining patient safety including clarity and conciseness of information.
UNASSIGNED: It is important that referral letters and discharge summaries are written clearly, concisely and comprehensively because nurses use them as key sources of evidence in planning and delivering care, and in communicating with other health professionals in relaying goals of care and implementing treatment plans.
CONCLUSIONS: Nurses reported that they regularly used referral letters and discharge summaries as valuable sources of evidence throughout their patients\' hospitalisation. The qualities of these documents which they most valued were language and communication styles, awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. This research has important impact on the patient experience in relation to encouraging effective referral letter and discharge summary writing.
UNASSIGNED: We have adhered to the relevant EQUATOR guidelines through the SRQR reporting method.
UNASSIGNED: No patient or public contribution.
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