七年制医学生病历书写技能的训练

Medical Record Writing Skills Training of the Seven-year Program Medical Students

长学制医学生病历书写技能的培训是临床实践中最基础的训练重点,是"三基"项目之一,是长期以来被社会各界重视的项目,是临床医学生将医学理论知识与临床实习相结合。通过病历的书写,准确的表达出来的教学结果,是检验医学生和临床教师优劣与否的标志。医学生与临床教师都应有相同的认知,需要双方共同的努力。不论是否为长学制医学生,无论是否手工书写、计算机打印、电子病历、病历书写技术、技能、技巧的培训和训练是一致的。让医学生在病历书写训练中知道、了解、掌握其中的重点,才能在有限的临床实习中将病历书写技术与临床能力的培养良好的结合,为成为执业医师做好准备。

Medical record writing skills training of seven-year program students is the most basic training in clinical practice, and is one of the ＂three basic＂ project, and this project has long been taken attention from all walks of life. It combines the medical theory and clinical practice. Through the medical record writing, accurately express the result of teaching is a sign of medical students and clinical teachers good or not. Medical students and clinical teachers should have the same cognition, and need a joint effort. Whether for long schooling medical students, whether the manual writing or computer printing, or electronic medical records, the medical record writing techniques, skills, skills training and training are the same. The medical students should master the key point of medical record writing training to make perfect combination of medical record writing technique and clinical ability in the limited clinical practice, and ready to become medical practitioners.