眼科住院医师规范化培训中病历书写的常见问题及改进措施  

Common problems analysis and improvements of medical records writing in the standardized residency training of ophthalmology

作　　者：苏钰[1] 陈长征[1] 严茜茜[1] 李璐[1] 贺涛[1] Su Yu;Chen Changzheng;Yan Xixi;Li Lu;He Tao(Ophthalmic Center,Renmin Hospital of Wuhan University,Wuhan 430060,China)

机构地区：[1]武汉大学人民医院眼科中心,武汉430060

出　　处：《中华医学教育探索杂志》2022年第11期1530-1533,共4页Chinese Journal of Medical Education Research

摘　　要：目的探讨眼科住院医师病历书写中的常见问题、原因及改进措施。方法收集武汉大学人民医院2019年9月至2020年1月有书写缺陷的病历100份,分析其问题构成及原因并提出对策。结果100份缺陷病历总计出现问题286个,病历内容缺陷89份,占31.12%;病历质量问题151份,占52.80%;其他问题46个,占16.08%。主要原因有自身态度问题、眼科基础知识薄弱、工作量大负担重、无规范化指导、与患者沟通不畅等。结论通过分析病历书写出现问题的主要原因,提出规范岗前培训、进行医疗纠纷案例和网络课堂学习、培养医患沟通能力、完善考核和评价系统等措施,可有助于减少眼科住院医师在病历书写中的问题。Objectives To investigate common problems analysis and improvements of medical records writing in the standardized residency training of ophthalmology.Methods A total of 100 defective medical records of Renmin Hospital of Wuhan University from September 2019 to January 2020 were collected and analyzed for the problems and the reasons,as well as the improvements.Results A total of 286 defects were found in these 100 medical records.Of which,content-related defects were detected in 89 medical records(31.12%),while quality-related problems were found in 151 records(52.80%).In addition,other defects were found in 46 records(16.08%).Major reasons included personal attitude,insufficient ophthalmic knowledge,heavy workload,lack of standardized guidance and insufficient communicational skills.Conclusion By analyzing the major reasons of medical records writing,the following approaches,including standardized pre-job training,learning of medical dispute cases and online training,communicational skills training,in-time feedback and evaluation improvement,would be help to reduce the defects in the medical records written by ophthalmic residents.

关 键 词：眼科 住院医师规范化培训 病历书写 

分 类 号：R276.7[医药卫生—中医五官科学]