特征提炼-集中点评教学法对提高内科住院医师病历书写质量的作用

Effect of characteristic summarizing and group training(CSGT)in improving the quality of internal medical record

目的探讨特征提炼-集中点评教学法对提高内科住院医师病历书写质量的作用。方法将2021年2月至2021年7月在中山大学附属第六医院内分泌科和风湿科轮科轮转的住院医师纳入研究,随机分为观察组和对照组。观察组教学第1周采用特征提炼式病历书写教学,第2周采用集中点评式教学,第3周起进行临床病历“一对一”修改点评教学;对照组教学第1周采用传统的病历书写教学,第2周起采用临床病历“一对一”修改点评教学。通过病历书写质量评分表评价两组教学效果。结果观察组病历书写质量(115.3±4.5)分高于照组(91.8±7.0)分(P<0.05)。培训后至少6个月中,观察组病历书写质量得分一直高于对照组。结论特征提炼-集中点评教学法可以持续高效地提升住院医师病历书写质量。对该教学法的持续开展和优化有利于住院医师病历书写水平的提高和临床思维的培养。

Objective This study aims to investigate the effectiveness of a noval education method named characteristic summarizing and group training(CSGT)in improving the quality of internal medicine inpatient records.Methods Residents who rotated in Department of Endocrinology and Rheumatology&Immunology,The Sixth Affiliated Hospital of Sun Yat-sen University,from February 2021 to July 2021 were selected and randomly divided into observation group(the CSGT group)and control group(traditional teaching group).For the residents in the observation group,characteristic summarizing were performed in the first week,and group based medical record reviewed were performed in the second week,followed by individualized record modification teaching.For the control group,conventional medical record writing instruction(1 st week)and individualized record modification teaching(from the 2 nd week)were provided.The teaching effects were evaluated through back-to-back medical record quality assessments.Results After training,the medical record quality of the CSGT group exhibited significant improvement compared to the traditional teaching group[(115.3±4.5)points vs(91.8±7.0)points,P<0.05].The effect of improvement in the CSGT group last for at least six months after training.Conclusion CSGT teaching method can continuously and effectively improve the quality of medical record writing among residents.Sustained implementation and optimization of CSGT will contribute to the enhancement of medical record writing skills and clinical thinking.