规范医学影像诊断报告书写,提高医学生及住院医师临床技能

Standardization of Radiology Report Writing can Improve Clinical Skills of Medical Students and Residents

医学影像诊断报告是正确行使医疗行为和保证医疗质量的依据,书写高质量的医学影像学诊断报告是医学生及住院医师必须掌握的一项基本功和基本技能。本文将结合我院长期的医学生及住院医师临床教学经验和实际,以神经系统影像报告为例,从医学影像诊断报告的重要性、医学生及住院医师医学影像诊断报告技能教学的现状、规范化医学影像报告书写技能的培养、评估、反馈和评价进行探讨,以期在医学生和住院医师的培养中提高其临床技能,供广大同道在医学教育与实践中借鉴和改进。

Radiology report is an evidence that to perform the best clinical practice and to ensure the quality of medical care. For medical students and residents, the ability to write a high-quality radiology report is one of basic skills whom must be mastered. In this article, using neuroradiology report as a paradigm, we will discuss the importance of radiology report, current situation of radiology report teaching, development of skill in standard radiology report writhing and the assessment, feedback and evaluation of standard radiology report for senior medical student and resident. All these discussions are based our long-term clinical teaching experiences, and we anticipate that these training can improve clinical skills for medical students and residents and can as a reference for other medical school or physicians.