建立实习医生完整病历批改质量监控体系在提高临床教师实习带教质量方面的作用探讨

The Investigation on the Establishment of Quality Assessment System for Correcting Intern’s Complete Medical Records about Improving Clinical Teachers’ Teaching Quality

目的本文通过对临床教师首次实习生完整病历批改情况开展的质量评价工作进行总结回顾,探讨建立实习医生完整病历批改质量监控体系在提高临床教师实习带教质量方面的可行性与必要性。方法通过对中山大学附属第一医院的内科、外科、妇产科、儿科及神经科5个教研室共23个实习病区的临床教学修改病历回收检查,采用抽样调查方法对完整病历的教学批改情况进行质量评价,同时由科室教学质量督导对带教老师病历修改情况进行评分,将评分结果向各个病区反馈。将病历批改质量评价结果作为临床教学质量评价的一个重要指标,与病区教学绩效挂钩。结果临床带教老师对于实习医生的病历评阅存在批改不规范,批改随意以及不完整等情况,部分手术科室情况尤为严重。结论目前临床病历书写教学存在多方面问题,亟须建立临床带教导师监督评价系统,加强临床教师对实习生教学工作质量的考核,进而增强临床教师的教学意识,促进师生互动交流与教学反馈,并有效促进临床教师的实习带教质量的提高。

Objective To investigate the necessity and feasibility of the establishment of quality assessment system for correcting intern’s complete medical records about improving clinical teachers’ teaching quality.Methods Interns’ complete medical records corrected by their clinical teachers in 23 wards from 5 Teaching Offices,including Department of Internal Medicine,Surgery,Obstetrics & Gynecology,Pediatric as well as Neurology.Quality assessment was performed,and the results were analyzed to investigate the clinical teachers’ correction quality of interns’ medical records as one the index of their teaching performance.Results Some clinical teachers’ teaching for the interns’ medical records were not enough,especially in some surgical departments.Conclusion There are several problems in the teaching of clinical interns’ complete medical records.It’s quite necessary to establish an effective quality assessment system for supervising the teaching quality of clinical teachers,which reinforces the teaching performance assessment in order to enhance their teaching awareness,to promote communication and interaction with interns as well as improving their clinical teaching quality.