— 照護管理 · MEDIUM · MCQ —
護理師正在協調將病人轉診至長期照護機構。轉診報告中必須包含哪些資訊？
A nurse is coordinating care for a client requiring transfer to a long-term care facility. Which information must be included in the transfer report?
- AThe nurse's personal notes about the client's personality護理師關於病人個性的個人筆記
- BRecent diagnostic test results and current medication administration records✓ 正解最近的診斷檢查結果和目前的藥物給藥紀錄
- CThe client's personal opinion about the staff on the current unit病人對目前病房工作人員的個人意見
- DDetailed family history including siblings and cousins詳細的家族史，包括兄弟姐妹和表親
— Explanation · 中文詳解 —
轉診交班（Hand-off report）的核心在於確保連續性照護（Continuity of care）。重點包括病史摘要、目前檢驗結果、用藥紀錄、照護計畫與特殊需求。A 為無關緊要的家族史；C 與 A 均屬於主觀意見，非醫療處置的核心必要資訊，應避免載入正式交班文件中，以維護專業客觀性。
A hand-off transfer report must ensure continuity of care. Essentials include diagnosis summary, current labs, MAR, care plan, and special needs. D is irrelevant family history; C and A are subjective opinions, not core clinical data, and should be excluded from a formal report to maintain professional objectivity.
✦ 台美臨床差異
美國利用 SBAR 模式極為普及；台灣雖然推行 SBAR，但在跨機構轉診時，資訊交換的標準化程度仍有落差。