新进临床医师《病历书写规范》岗前培训与考核成绩评价  

The Pre-post Training of The Specification of the Documentation of the Medical Record and the Evaluation of the Result

作　　者：杨建南[1] 雷跃昌[1] 李勤[1] 李世云[1] 李陵[1] 方进仁 唐红[2] 

机构地区：[1]四川省成都铁路中心医院 [2]四川省成都市医学信息所

出　　处：《中国病案》2008年第1期41-43,共3页Chinese Medical Record

摘　　要：目的探讨加强对新进临床医师的《病历书写规范》岗前培训与考核,保障医疗安全。方法对某院2006年～2007年公招和招聘的47名本科以及博硕士临床医学毕业生进行入科前《病历书写规范》培训,课后行闭卷考试,对考试成绩进行统计分析,并与该院同期187名临床医学本科实习生培训考核成绩作对照分析。结果新入临床医师考试成绩:(1)2007年较2006年有明显提高(P<0.05)。(2)考试成绩普遍不如临床医学本科实习生。(3)17名取得执业医师执照者(其中博硕士10人),病历书写规范考试成绩并不理想,不及刚毕业的本科生。结论(1)高等医学院校要加强医学生病历书写基本功的培养和考核,同时,按《病历书写基本规范》的要求对《诊断学》中关于病历书写相关章节进行修订。(2)医院应将质控的重心从终末质控转移到基础质量控制和环节质量控制上来,强化对病历书写者的岗前教育和质量教育,并将临床医师病历书写质量纳入卫生专业人员服务能力的考核评价。(3)建议卫生行政部门将《病历书写基本规范》相关内容纳入执业医师资格考试题库之中。Objective To strengthen the training and the evaluation of The Specification of the Documentation of the Medical Record for the pre - post clinicians to guarantee medical security. Method To take prepost training and closed - book examination about The Specification of the Documentation of the Medical Record for forty - seven clinical graduates with bachelor, doctoral or master degree newly recruited in public or not public in 2006 and 2007 and to do a statistical analysis on the result and then we made a contrast analysis between the result and that from 187 housemen who are doing the medical practice in the same hospital. Result （ 1 ） The scores of new clinicians in 2007 are higher than that in 2006 （P 〈 0.05） ; （2） generally, the result is lower than that of medicos; （3） the result of seventeen doctors with license including ten with doctoral ＆ master degree is less than that of new graduated medical students. Conclusion （ 1 ） Medical colleges should fortify the basic training and examination on the Documentation of the Medical Record, and revise the related chapters in Diagnosis according to The Specification of the Documentation of the Medical Record. （2） The Focus of quality control of the medical record should be moved from end quality control to basic and links＇ quality control, and we should strengthen prepost training of the documentation the medical record, and bring the doctors＇ quality of the documentation of the medical record of into his or her evaluation of practical service ability. （3） Medical Administrative departments should internalize related content of The Specification of the Documentation of the Medical Record into the library of examination question for practical doctors.

关 键 词：医学生 临床医师 病历书写规范 培训 医疗质量控制 

分 类 号：R-4[医药卫生]