关于提高实习生病史采集和病历书写质量的思考

On Improving the Medical Interns' Ability of History-taking and the Writing Quality of Medical Records

病史采集和病历书写是医学生实习期间必须掌握的基本临床技能,更是对学生临床诊断思维能力的考验和锻炼。提高实习生病史采集与病历书写质量,需要注重岗前教育,实习过程中应强化带教引导和指导责任,并经常开展病史采集和病历书写竞赛活动等。

History-taking and medical records＇ writing is a fundamental technology that should be mastered by medical trainee in the course of internship;it is also the practice and examination of the students＇ clinical thinking ability.Improving the quality of history-taking and medical records depends on the pre-position education,and the enforcement of instruction and guiding responsibility.Occasional competitive campaigns are also suggested.