结合病例大赛探讨外科住院医师问诊及病历书写的现状与提升对策

Present problems and promotion ways of consultation and medical records in surgical residents through clinical case competition

目的 以广东省第一届住院医师病例大赛为契机,探讨外科住院医师问诊和病历书写的现状与提升对策。方法 在大赛初赛前,调研中山大学附属第三医院2019年1月至2020年3月间102份包含腹痛为主诉的结直肠癌患者初诊的病历资料,发现病史问诊及首次病程记录书写缺陷比例较高,均超过60%。在复赛前,采用标准化病人问诊以及批判性复盘方法培训。结果 经过赛前培训后,住院医师病史问诊及首次病程记录成绩明显提升。复赛后1年回访,住院医师表示该培训对提升问诊条理性及临床思维能力有帮助。结论 外科住院医师病史问诊和首次病程记录书写仍有很大提升空间,短期集中培训可以作为日常带教的重要补充,但是具体实施方法仍需要进一步探索。

Objective To explore the present problems and promotion ways of consultation and medical records in surgical residents through the first clinical case competition in Guangdong Province. Methods Before the preliminary contest, 102 finished medical records between January 2019 to March 2020, which contained abdominal pain as chief complaint, were investigated. High rate of clinical thinking deficit was found in present history and the first course record(all exceeded 60%). SP consultation and judgmental debriefing were used in the training course before semi-final competition. Results The residents achieved great progression in these two fields after training.Questionnaires before and 1 year after the competition showed that the training course could do good help to the consultation organizing and clinical thinking. Conclusion Consultation and medical record writing are still needed to be improved. The short term training course could be used as an important supplement for advancing the ability of them during the daily teaching, while further research needs to be done to find the suitable teaching method.