提高实习生病历书写质量教学管理体会

Our Experience in Raising the Teaching Quality of Interns' Medical Record Writing

病历书写是医务工作者从事医疗活动的最基本行为,也是医学生实习要掌握的的最重点内容。临床教学管理中发现,医学实习生普通存在着病历书写能力不足,病历书写质量和问诊、查体等临床基本技能差的问题,许多实习同学甚至包括不少新毕业医生的病历书写错漏百出,前后矛盾。广东医学院附属三水医院近几年来一直注重规范实习生病历书写,提高实习生病历书写能力,效果显著。

Medical record writing is the basic behavior of medical workers engaged in medical activities and is also the most important skill needed by interns.Our practice in clinical teaching management shows that interns lack the capacity of medical record writing,inquisition and physical examination.Many interns and even new medical graduates often make mistakes in medical record writing.Our hospital has been paying constant attention to interns＇ medical record writing in these years and has achieved significant results.