·临床教学·临床医学专业实习生病例书写问题分析及对策探讨.PDFVIP

中华临床医师杂志( 电子版)2016 年2 月第10 卷第4 期 Chin J Clinicians(Electronic Edition),February 15,2016,Vol.10,No.4 ·599 · ·临床教学· 临床医学专业实习生病例书写问题分析 及对策探讨 迟云飞 徐成峰 陈琦 冯瑞 柴家科 【摘要】目的 提高临床医学专业实习生病历书写质量，改善临床教学效果。方法 选择2013 年1 至12 月在我院实习的临床医学专业本科实习生60 名，完全随机分为教学改进组（30 名）和对 照组（30 名），教学改进组实习生实习期间进行针对性病历书写辅导教学，两组实习生分别于实习 期第3 个月、第6 个月进行两次病历书写质量评分，将两组内两次评分结果和两组间第二次评分结 果进行统计学分析。结果 教学改进组实习生针对性教学后病历书写质量评分（81.80 ±5.01 ）显著 高于教学前（75.00 ±7.82 ），差异具有统计学意义（P=0.000 2 ）。教学改进组（81.80 ±5.01 ）与对照 组第二次评分结果比较，病历书写质量评分显著高于对照组（79.07 ±4.65 ），差异具有统计学意义 （P=0.032 6 ）。结论 病历书写辅导的针对性教学，对实习生病历书写质量的提高，整体诊疗思路 的建立均有积极作用，显著提高了临床实习效果 【关键词】 实习生； 病历； 教学 Analysis of medical records problem and discussion of teaching methods for the clinical medicine interns Chi Yunfei, Xu Chengfeng, Chen Qi, Feng Rui, Chai Jiake. Department of Burn and Orthopedics Surgery, the First Affiliated Hospital of PLA General Hospital, Beijing 100048, China Corresponding author: Xu Chengfeng, Email: kyggyx1@126.com 【Abstract 】 Objective To improve the quality of medical records of clinical medicine intern and to improve the teaching effectiveness. Methods Sixty clinical medicine interns who practiced in our hospital at 2013 were selected and were divided to teaching group (n=30) and control group (n=30), during the 3 months, we gave the interns of teaching group two times special teaching to help them to improve the quality of medical records. The clinical medicine interns in both groups accepted two times medical record writing assessment at the third month and sixth month of internship respectively. At the sixth month the assessment scores between the two groups and the two times scores of each group were compared. Results The assessment scores after medical record