{"id":10735,"date":"2024-12-11T14:30:39","date_gmt":"2024-12-11T13:30:39","guid":{"rendered":"https:\/\/extali.eu\/docs\/4-informationswesen\/4-1-dokumentation\/4-1-12-patientenbezogene-berichte-arztbrief\/"},"modified":"2024-12-16T23:38:42","modified_gmt":"2024-12-16T22:38:42","slug":"4-1-12-rapports-relatifs-aux-patients-lettre-du-medecin","status":"publish","type":"docs","link":"https:\/\/gutehospitalpraxis.de\/fr\/handbuch\/4-informationswesen\/4-1-dokumentation\/4-1-12-patientenbezogene-berichte-arztbrief\/","title":{"rendered":"4.1.12 Rapports relatifs au patient, lettre du m\u00e9decin"},"content":{"rendered":"<div class=\"wp-block-file\"><a id=\"wp-block-file--media-8ffaf2e3-fe4d-42d8-8dbe-0c97fc850799\" href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2024\/12\/4.1.12_00_qm_arztbericht.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">T\u00e9l\u00e9charger l'AP au format PDF <\/a><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2024\/12\/4.1.12_00_qm_arztbericht.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-8ffaf2e3-fe4d-42d8-8dbe-0c97fc850799\">T\u00e9l\u00e9charger<\/a><\/div>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"ziel_und_zweck\">Objectif et but<\/h2>\n\n\n\n<p>Les rapports doivent \u00eatre transmis en temps voulu aux services \u00e0 l'int\u00e9rieur et \u00e0 l'ext\u00e9rieur de l'h\u00f4pital qui assument la responsabilit\u00e9 du traitement ou des soins des patients. En tant que document de synth\u00e8se, la lettre de sortie rev\u00eat une grande importance en termes de communication. Des r\u00e8gles doivent \u00eatre \u00e9tablies pour la r\u00e9daction du contenu et des aspects techniques.<\/p>\n\n\n\n<p>Le rapport doit toujours contenir le motif de l'admission ou du transfert du patient, le diagnostic, les examens et les proc\u00e9dures de traitement effectu\u00e9s ainsi que leurs r\u00e9sultats, les prescriptions de m\u00e9dicaments et une pr\u00e9sentation de l'\u00e9tat de sant\u00e9 au moment du transfert.<\/p>\n\n\n\n<p>La lettre de sortie doit en outre mentionner les maladies concomitantes, la m\u00e9dication pendant l'hospitalisation, une description de l'\u00e9volution et une description de l'\u00e9tat \u00e0 la sortie (am\u00e9lior\u00e9, inchang\u00e9), des recommandations pour la suite du traitement et un plan de suivi.<\/p>\n\n\n\n<p>La lettre de sortie (\u00e9picrise) doit \u00eatre r\u00e9dig\u00e9e par une personne d\u00fbment qualifi\u00e9e.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"anwendungsbereich\">Application<\/h2>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"beschreibung\">Description du d\u00e9roulement<\/h2>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"beschreibung\">Risques<\/h2>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"dokumentation\">Ressources <\/h2>\n\n\n\n<h4 class=\"wp-block-heading\">Mat\u00e9riau<\/h4>\n\n\n\n<h4 class=\"wp-block-heading\">Temps n\u00e9cessaire<\/h4>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"ressourcen\">Documentation<\/h2>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"zustaendigkeit_und_qualifikation\">Comp\u00e9tence et qualification<\/h2>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"hinweise_und_anmerkungen\">Remarques et commentaires<\/h2>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"mitgeltende_unterlagen\">Documents \u00e0 joindre<\/h2>\n\n\n\n<h4 class=\"wp-block-heading\" id=\"literatur\">Documents de validation<\/h4>\n\n\n\n<h4 class=\"wp-block-heading\" id=\"begriffe\">Termes<\/h4>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"anlagen\">Placements<\/h2>\n\n\n\n<div class=\"wp-block-file\"><a id=\"wp-block-file--media-2479b870-0fdf-4afe-8341-545ea0da16ef\" href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2024\/12\/4.1.12_01_qm_arztbericht_formular.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Formulaire pour une lettre de m\u00e9decin<\/a><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2024\/12\/4.1.12_01_qm_arztbericht_formular.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-2479b870-0fdf-4afe-8341-545ea0da16ef\">T\u00e9l\u00e9charger<\/a><\/div>\n\n\n\n<div class=\"wp-block-file\"><a id=\"wp-block-file--media-66c1f684-0078-4b73-a2b9-1aa02eb32f7e\" href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2024\/12\/4.1.12_02_qm_muster_arzbrief.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Mod\u00e8le de lettre m\u00e9dicale<\/a><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2024\/12\/4.1.12_02_qm_muster_arzbrief.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-66c1f684-0078-4b73-a2b9-1aa02eb32f7e\">T\u00e9l\u00e9charger<\/a><\/div>\n\n\n\n<p><\/p>","protected":false},"excerpt":{"rendered":"<p>Ziel und Zweck Berichte sollen zeitgerecht an die Stellen im und au\u00dferhalb des Krankenhauses weitergeleitet werden, die f\u00fcr die Behandlung oder Versorgung der Patienten Verantwortung \u00fcbernehmen. Der Entlassungsbrief hat als zusammenfassendes Dokument gro\u00dfe kommunikative Bedeutung. F\u00fcr die inhaltliche und technische Erstellung sind Regeln aufzustellen. Der Bericht soll immer den Grund f\u00fcr die Aufnahme oder \u00dcberweisung [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10711,"menu_order":12,"comment_status":"open","ping_status":"closed","template":"","doc_tag":[],"doc_badge":[],"class_list":["post-10735","docs","type-docs","status-publish","hentry","no-post-thumbnail"],"acf":[],"author_avatar":"https:\/\/secure.gravatar.com\/avatar\/c6b2616140d9fcd6a1c5d6d2ebbf43422308c9322c032ef03f88ec3235855dcf?s=96&d=mm&r=g","author_name":"admin","_links":{"self":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10735","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs"}],"about":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/types\/docs"}],"author":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/comments?post=10735"}],"version-history":[{"count":0,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10735\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10711"}],"wp:attachment":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/media?parent=10735"}],"wp:term":[{"taxonomy":"doc_tag","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/doc_tag?post=10735"},{"taxonomy":"doc_badge","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/doc_badge?post=10735"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}