CBS模式在住院医师病历书写规范化培训中的应用

Application of Case-based Study Mode in Medical Records Writing Standardized Training for Residents

目的研究以病案为基础教学法(CBS)在病历书写规范化培训中的应用效果。方法以某院2016年100名住院医师规范化培训学员为研究对象,随机分为试验组(n=50)和对照组(n=50),分别采用CBS模式和传统模式进行培训,比较2组学员培训前后的理论考试成绩和病历书写质量评分,并发送培训效果反馈问卷调查表。计数资料采用χ2检验比较两组间差异,计量资料采用t检验进行统计分析,以P<0.05为差异有统计学意义。结果在住院医师病历书写规范化培训中,无论是理论考试成绩还是病历书写的规范性和完整性评分,接受CBS培训模式组(97.06±2.22,96.14±2.91,97.86±1.59)均显著高于传统模式组(93.02±4.07,91.14±4.63,95.44±2.64),差异有统计学意义(P<0.05)。结论 CBS培训模式能够通过提升学员的课堂注意力、学习兴趣和记忆效果,从而提高住院医师的理论知识水平和病历书写能力及质量。

Objective To study the application of case-based study method in the standardized training of medical record. Methods A total of 100 residents were selected as the subjects and randomly divided into test group （n = 50） and control group （n = 50）. The CBS model was used for test group while the traditional model was used for control group. The scores before and after the training of theoretical test and medical record writing quality between two groups were compared and the training feedback questionnaires were send to analysis of the training effect of two groups. Results In the standardized training of record for residents, no matter the theoretical test scores or the normative and integrity scores of writing medical record, the trainees of the CBS training model group were significantly higher than those in the traditional model group （97.06 ± 2. 22, 96. 14 ± 2. 91, 97.86 ± 1.59 vs. 93.02± 4. 07, 91.14 ± 4. 63, 95.44 ± 2. 64; P〈0. 05, respectively）. Conclusion CBS training mode can improve the level of theoretical knowledge and the ability and quality of writing medical record by improving the trainees＇ classroom attention, learning interest and memory effect.