临床实习教学文档的评价与思考

Evaluation and thinking of clinical practice teaching files

目的通过对临床实习教学文档的检查评价与思考，以促进科室临床实习教学文档建设，提高临床教学水平。方法选择某军医大学附属医院2015年秋季学期教学的18个临床科室实习教学文档为检查对象，检查项目分为实施计划、实施记录和实施总结三部分15项，量化评价每项2分，数量分和质量分各占1分。评价结果换算100分制。结果18个临床科室实习文档，90分以上4个，80～89分8个，70，79分3个，60～69分3个。妇产、辅诊和急诊科得分排在前三位；大外科和大内科各项得分没有明显差异：专科各项得分均较低。大部分临床科室实习文档资料比较健全、记录完整，部分科室有缺项或文档记录不完整、不规范。结论临床实习教学文档的检查、量化评价客观反映临床科室实习教学质量．为加强实习文档建设、提高临床教学水平提供依据。

Objective Tocheck and evaluate on clinical practice teaching files for providing a foundation of improved clinical teaching levels with enhanced establishment~ of practice teaching files. Methods The practice teaching files of eighteen clinical departments in a military medical university were selected as the subject and were evenly divided into teaching plans and teaching records as well as teach- ing summary three parts and 15 items. Each item had 2 scores in which quantity had one score and quality has another one. Evaluation results were converted into 100 points system. Results Among practice teach- ing files of eighteen clinical departments, 4 scored more than 90, 8 scored between 80 to 89, 3 scored between 70 to 79, 3 scored between 60 to 69. Three advanced departments are obstetrics and gynecology, auxiliary department and emergency department. There were no significant differences in the scores of major surgery and internal medicine. Compared with that of other departments in the hospital, the specialty of hospital had low scores. It showed that most of the clinical practice of the file information was relatively sound with complete records and some departments had missing items or incomplete and non-standard doc- umentation records. Conclusion Qualitative study on practice teaching files can reflect clinical practice teaching quality. And it is meaningful for us to enhance teaching files construction and to improve clinical practice teaching levels.