对临床实习生书写病历质量检查的分析与体会

Analysis and experience of case history writing quality check of interns

为不断提高临床实习生实习阶段的教学质量,完善教学质量监控体系。对二年中的二届临床实习生,在实习期间所写病历的质量进行检查。每位实习生随机抽查1份病历,共162份,涉及内科、外科、妇产科、儿科四个教研室的各专业。由教学质量督导专家对每份病历根据书写情况及带教老师的修改情况进行打分。结果显示,病历修改中专家评分低于教师的评分;专家评分失分的分析显示,在楣栏、治疗和卷面三项中的失分病历数比例和失分也较有所减少。说明通过对实习生在临床实习阶段教学质量督导,临床教师的教学意识有所加强。从病历质量的变化显示医学生的临床实践能力有所提高。

In order to strengthen the administration of clinical practice education, case history writing quality of 2000 and 2001 grades interns during their internship has been checked. One case history report per intern was selected in random. There are 162 history reports, which are related to the subspecialfies of surgery, gynecology, obstetrics and pediatrics. Both the case history writing quality of medical students and the amendments by clinical teachers have been scored by experts organized by clinical medical school. The results indicate that the marks given by the experts are less than those given by the clinical teachers, but the proportion of mark lost cases and points loss in top-column, treatment plan and writing criterion are lessened. It is concluded that education sense of clinical teachers have been improved and the clinical practice ability of medical students has been heightened under the strengthening policy of the quality supervising in clinical practice period.