临床医生岗前培训中病历书写缺陷分析

DISCUSS ON THE NECESSITY OF CLINICIANS' PRE-THE-POST TRAINING IN VIEW OF THE MEDICAL HISTORY WRITING DEFECT

目的加强住院医生及进修医生对病历书写的基本功训练。方法随机抽取我院近两年来由住院医生及进修医生书写的病历600份并进行分析。结果有书写缺陷的病历为312份,缺陷率为52%,其中现病史书写缺陷率最高,为34%。结论住院医生及进修医生应加强岗前培训,重点掌握现病史的采集及描述,以提高病历书写质量。

Objective To strengthen the residents and advanced training physician's basic skills of medical history writing. Methods Collecting randomly and analyzing 6 hundred portions of medical history, written by the residents and advanced training physicians in the two recent years in our hospital. Result 312 portions of them had writing defect and its defect rate was 52%. Among these, the defect rate of present history writing was the highest, reached 34%. Conclusion Residents and advanced training physicians should strengthen their pre-the-post training and well grasp their skills of present history's collection and description so as to improve their writing ability.