实习医师病历书写教学方法的研究与评价

Research and Evaluation of the Teaching Method of Medical Records Writing in Clinical Internship

目的探讨实习医师病历书写教学方法对病案质量的影响。方法对医师进行培训、考核并督导其完成量化的实习内容,比较实施前后的考核指标。结果方法实施后,病历平均质量评分由85.06分提高到92.43分(P<0.001),病历优秀率由5.5%提高到33.4%(P<0.001),病历平均缺陷率由49.8%降低到23.3%(P<0.001)。结论此方法增强了实习医师的病历质量意识,有利于提高病历内涵质量。

Objective To investigate the impact of the teaching method of medical records writing in clinical internship on the quality of medical records, Methods The interns involved in the teaching method of medical records writing were accepted training, assessment, and promoted to finish the quantitative clinical practice, and the assessment indicators were compared before and after theapplication. Results After the implementation of the method, the average score of quality of medical records increased from 85.06 points to 92.43 points（P 〈 0.001）,the rate of excellent medical records increased from 5.5% to 33.4%（P〈 0.001） and the aver- age rate of defect decreased from 49.8 % to 23.3 % （P 〈 0.001）. Conclusion It enhances the consciousness of medical record quality of interns, and contributes to the improvement of the quality of medical records.