外科临床实习病历书写存在的问题及对策

Analysis of Medical Records Written by Interns in Surgical Practice and Quality Control Measures

外科实习普遍只重视实践技能操作,病历书写往往不受重视,致使外科实习病历书写问题尤其突出,既不利于学员临床思维能力的培养及业务水平的提高,更可能加剧医患纠纷。外科病历有其独特性,除了更注重专科查体外,更重要的是病史采集不准确或不全面,会影响手术指征的把握,不合时机的手术会给患者造成巨大的伤害。针对外科病历书写中现存的问题,笔者认为应从学生、教员两方面入手,加强病案观,通过学员岗前培训、师资培训,定期病历讲评、举办病历书写比赛、建立病历分数登记制度等措施来提高外科病案书写的质量。

Interns generally only attach importance to practical skills in surgical practice. Problem is particularly prominent in medical records writing which is often ignored by surgical intern. It is harmful to the cultivation of students＇ clinical thinking ability and more likely to aggravate medical disputes. Surgical records pay more attention to specialized physical examination. The inaccurate or incomplete history collecting will lead to a incorrect operation which would cause great harm to patient. We believe that pre-job training of students, teacher training, periodic reviews, medical records writing competition, establishing a registration system for scores will improve the quality of surgical records writing.