摘要
目的了解全科住院医师书写全科电子版首次病程录(简称首程)质量,为开展病历书写教学活动提供对策。方法对2021年4月至2022年3月全科住院医师在全科病房轮转期间书写的首程,按自行编制的评分表进行双人评价。结果共纳入评价首程134份,含2019级43份,2020级66份,2021级25份。首程评分中最高分95.5分,最低分73.0分,平均分84.3分,总合格率78.36%。在不合格率、诊断准确性和诊治对应扣分项中,2019级与2020级比较,差异有统计学意义(P<0.05)。除上述3项外,在合格率、其他病史概括、体格检查、一般治疗、药物治疗和其他治疗扣分项中,3个年级间比较,差异有统计学意义(P<0.05)。结论全科住院医师的首程书写质量有待提高,指导医师应重视病历书写教学,加强书写全过程指导,发挥电子病历优势,采取有效策略激发住院医师主观能动性,提高书写技能和临床诊疗思维能力。
Objective To investigate the writing quality of the first medical record by residents in standardized training of general practice,and provide countermeasures for teaching.Methods From April 2021 to March 2022,the electronic first medical records written by the general practitioners in the ward were selected,and the two-person evaluation was made according to the self-made rating scale.Results A total of 134 first medical records were evaluated:43 in Grade 2019,66 in Grade 2020 and 25 in Grade 2021.The highest score was 95.5,the lowest score was 73.0,the average score was 84.3,and the total qualified rate was 78.36%.In the deduction items of"disqualification rate""diagnostic accuracy"and"correspondence to diagnosis and treatment",there were statistically significant differences between the Grade 2019 and Grade 2020(P<0.05).In addition to the above 3 items,in the deduction items of"qualification rate""other medical history summary""physical examination""general treatment""drug treatment"and"other treatment",these items were statistically significantly different in the three grades of residents(P<0.05).Conclusion The quality of the first medical record writing of general practitioners needs to be improved.Tutors should pay attention to the significance of medical record writing,strengthen the guidance of the whole process of writing,give full play to the advantages of electronic medical records,and adopt effective strategies to stimulate the initiative of general practitioners,so as to improve their writing skills and clinical diagnosis and treatment thinking ability.
作者
蒋巧巧
李巧云
陈童恩
Jiang Qiaoqiao;Li Qiaoyun;Chen Tongen(Department of General Medicine,Ningbo No.2 Hospital,Ningbo 315000,Zhejiang,China)
出处
《中国毕业后医学教育》
2023年第8期669-672,共4页
Chinese Journal of Graduate Medical Education
基金
中国科学院大学宁波华美医院“华美科研”项目(2021HMKY32)。
关键词
全科医师
住院医师规范化培训
首次病程录
教学
general practitioners
standardized residency training first medical record
teaching
