住院规范化培训医师操作规范的现状研究

Current Situation of Operation Standard in Standardized Resident Training Physician

目的探讨内科住院医师规范化培训人员病史采集,体格检查和胸腔穿刺抽液操作规范程度。方法对2018年1月-2019年10月纳入本院住院医师规范化培训内科组的100名学员进行考核,考核内容包括针对胸痛患者的病史采集,体格检查,以及对胸腔穿刺抽液操作规范程度。结果住院医师病史采集平均不合格情况中"现病史(伴随症状)"不合格率最高,其次为"基本信息"及"现病史(疾病演变过程)"。住院医师体格检查不合格情况中"触诊"不合格率最高,其次为"准备工作"、"视诊"。住院医师胸腔穿刺抽液不合格情况中"结果(是否抽出液体)"及"人文关怀"不合格率最高,其次为"无菌"。结论住院医师规范化培训中的教学方法和评估体系仍有提升空间。

Objective To explore the standardization degree of medical history collection, physical examination and thoracentesis operation of medical resident standardized training personnel. Methods From January 2018 to October 2019, 100 trainees who were included in the internal medicine group of the hospital’s resident standardized training were assessed, including the medical history collection, physical examination, and the standardized degree of thoracic puncture and fluid extraction. Results Among the average unqualified cases of medical history collection, the unqualified rate of "current medical history(accompanied by symptoms)" is the highest, followed by "basic information" and "current medical history(disease evolution process)". In the case of unqualified physical examination, the unqualified rate of palpation is the highest, followed by preparation and visual examination. The results(whether to extract the liquid) and humanistic care were the most unqualified cases, followed by asepsis. Conclusion Improvement is needed for teaching methods in the standardized training of medical residents.