从病历质量看住院医生培养中的问题  

Problems in resident physicians training by analyzing quality of medical records and their solutions

作　　者：梅晶[1] 王琳[1] 

机构地区：[1]第三军医大学大坪医院野战外科研究所神经内科,重庆400042

出　　处：《重庆医学》2011年第16期1614-1615,1618,共3页Chongqing medicine

摘　　要：目的探讨临床住院医师培养中的问题和应对策略。方法以"失眠症"、"慢性失眠"、"焦虑-抑郁状态"、"躯体形式障碍"等作为关键词,从大坪医院病历数据库抽取2010年1月1日至6月30日出院的全部病历,采用自编表格分析病历质量。结果 31.5%病历将主诉写成睡眠障碍;42.4%～70.1%的现病史对睡眠质量未作详细记录;84.3%的病史特点复制现病史,拟诊讨论过于简单;46.3%的最后诊断术语不准确。结论住院医师缺乏有关失眠的基本知识和理论,应加强住院医师基本理论和技术的学习。Objective To discuss problems of resident physicians training and their solutions.Methods Collect medical records of discharged patients from 1 January 2010 to 30 June 2010 from medical history information database of Daping hospital according to keywords such as insomnia,chronic insomnia,anxiety-depression and somatoform disorders,and self-created form was adopted to analyze quality of medical records.Results Sleep disorder was recorded as the chief complaint by mistake in 31.5% medical records.History of present illness in 42.4%-70.1% medical records did not contain detailed descriptions of sleeping quality.The clinical history characteristics in 84.3% medical records were copies of their history of present illness with superficial discussions for preliminary diagnosis.46.3% medical records had inaccurate terms of final diagnosis.Conclusion Some resident physicians lack basic knowledge and theories related to insomnia,and their learning of fundamental theories and technology should be enhanced.

关 键 词：病历质量 失眠 住院医师 教育 

分 类 号：R197.3[医药卫生—卫生事业管理]