儿科住院医师入院记录质量分析及带教策略

Quality analysis of pediatric admission records by resident physicians and the guidance and teaching methods

目的分析住院医师书写儿童医院呼吸科入院记录中的常见缺陷,为住院医师规范化培训的临床带教提供参考。方法抽取2021年9月—2022年2月重庆医科大学附属儿童医院呼吸科住院医师书写的入院记录60份,由指导医师判定其缺陷,引导住院医师分析并解决病历中的问题,指导住院医师进行病情判断和病历书写。结果住院医师入院记录的常见错误涵盖儿科入院记录的所有板块,其中现病史、生长发育史、体格检查和诊断是错误最常见的板块。住院医师诊疗技术水平、医疗思维和法律意识是需要加强培训的重点环节。结论本研究就住院医师书写的儿科入院记录常见缺陷提出了带教建议,不仅可以提高住院医师入院记录质量,还可以体现医务人员的人文关怀。

Objective To find the common defects of pediatric respiratory admission records by resident physicians,and to provide guidance and teaching methods for standardized residency training.Methods A total of 60 pediatric respiratory admission medical records,which were written by 21 resident physicians from September 2021 to February 2022,were analyzed to find the common defects.Guidence teachers analyzed the quality of admission records,guided the residents to analyze and deal with the defects in the medical records,and taught resident physicians to diagnose the disease and write the medical records.Results Common defects made by resident physicians in writing the admission history covered all sections of the admission record,among which the history of present disease,growth history,physical examination and diagnosis were the most common error parts.It needed to be strengthened in the diagnosis and treatment of the diseases,medical thinking and legal awareness for resident physicians.Conclusion By analyzing the common defects of pediatric respiratory admission records written by residents,this study provides guidance and teaching methods,which may not only be used to reduce the defects of admission records,but also show more humanistic care among medical colleagues.