与临床思维相结合的首次病程记录培训方法和效果探析

Exploration of Training Methods and Effects for Initial Medical Record Documentation Combined with Clinical Thinking

首次病程记录的书写质量反映了医生对疾病的综合分析和处置能力.通过不同指导方式对实习医生首次病程记录进行培训,将病历修改纳入常规临床教学实践评价,能有效提高医学生病历记录书写质量,提升医学生临床综合思维能力和人文化医患沟通能力.

To explore the effectiveness of training methods for initial medical record documentation when combined with clinical thinking,and to assess their impact on the quality of medical record writing.This study involved training for interns on initial medical record documentation using different guidance methods.The training incorporated regular clinical teaching practices and evaluations of medical record modifications.The quality of medical records and the interns'abilities in clinical comprehensive thinking and patient communication were assessed.The training methods that integrated clinical thinking significantly improved the quality of medical records,enhanced the interns'comprehensive clinical thinking abilities,and improved their humanistic communication skills with patients.Incorporating clinical thinking into the training for initial medical record documentation effectively enhances the writing quality of medical records,and contributes to better clinical thinking and patient communication skills among medical students.