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住院医师住院病案首页专项培训效果评价 被引量:5

Evaluation of Special Training on Home Page of Inpatient Medical Records for Residents
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摘要 目的对某院住院医师住院病案首页专项培训效果进行分析,探讨提高住院病案首页质量的方法。方法以某院2018年1月1日-2020年5月31日期间入职住院医师共105人为研究对象,随机分为对照组55人和实验组50人,对照组参与医院常规培训,实验组在常规培训基础上开展为期2个月的住院病案首页专项培训。专项培训结束后进行问卷调查及专题考试,年终进行两组住院医师病案首页质量追踪考核。结果实验组住院医师住院病案首页填写完整率为98%,准确率为92%,专题考试平均得分为(97.38±2.21)分,均明显高于对照组,除填写完整性外组间差异均具有统计学意义,P<0.05;问卷结果显示,实验组住院医师总满意度为(4.22±0.58)分,高于对照组(3.05±0.73)分,且在增强责任心、掌握填写规则、提升沟通表达能力,培训形式与推广性的评价上也高于对照组,组间比较,差异具有统计学意义,P<0.05。结论专项培训可以让住院医师注重体验和参与,在实践中深入学习,从而快速、高效率掌握住院病案首页填写要点,把好质控第一关,可真正从本质上提升住院病案首页数据内涵质量。 Objective Analyze the effect of special training on the first page of medical records for residents in a hospital.To explore the methods to improve the quality of the first page of inpatient medical records.Methods Total of 105 resident doctors enrolled in a hospital from January 1,2018 to May 31,2020 were selected as the research subjects.They were randomly divided into the control group(50)and the experimental group(55).The control group participated in the regular hospital training,while the experimental group received a 2-month special training on the first letter of inpatient medical records on the basis of the regular training.After the special training,questionnaire survey and special examination were conducted.At the end of the year,the quality of the first page of medical records of the two groups of residents was tracked and assessed.Results The completion rate of the first page of the medical records of residents in the experimental group was 98%,the accuracy rate was 92%,and the average score of the special examination was(97.38±2.21),which were significantly higher than the control group,except for the completion of the medical records,the differences between the groups were statistically significant(P<0.05).The results of the questionnaire survey showed that the total satisfaction of residents in the experimental group was 4.22±0.58,which was significantly higher than that of the control group 3.05±0.73,indicating that the special training form was flexible and novel,could better master the filling rules,improve the ability of communication and expression,and had a high degree of generalization,and the difference between groups was statistically significant(P<0.05).Conclusions Special training enables residents to focus on experience,participation,and in-depth learning in practice,so as to quickly enhance their sense of responsibility,efficiently master the key points of filling in the first page of inpatient medical records,and properly control the first pass of quality,which can really improve the quality of data connotation of the first page of inpatient medical records in essence.
作者 刘锐 孔彬 成宏伟 徐康 沈晓蓉 Liu Rui;Kong Bin;Cheng Hongwei;Xu Kang;Shen Xiaorong(Taixing People's Hospital,Taizhou 225400,Jiangsu Province,China;不详)
出处 《中国病案》 2021年第12期66-68,共3页 Chinese Medical Record
基金 江苏省医院协会医院管理创新研究课题(JSYGY-3-2019-38) 泰兴市人民医院院级基金课题(try1920)。
关键词 住院医师 住院病案首页 专项培训 Resident Medical record home page Special training
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