关于提高实习生病史采集和病历书写质量的思考  

On Improving the Medical Interns' Ability of History-taking and the Writing Quality of Medical Records

作　　者：桑爱民[1] 周庆[1] 戴林[1] 吴彩霞[1] 袁芳[1] 陈晓庆[1] 

机构地区：[1]南通大学附属医院,江苏南通226001

出　　处：《江苏海洋大学学报（人文社会科学版）》2011年第18期99-100,共2页Journal of Jiangsu Ocean University（Humanities & Social Sciences Edition）

摘　　要：病史采集和病历书写是医学生实习期间必须掌握的基本临床技能,更是对学生临床诊断思维能力的考验和锻炼。提高实习生病史采集与病历书写质量,需要注重岗前教育,实习过程中应强化带教引导和指导责任,并经常开展病史采集和病历书写竞赛活动等。History-taking and medical records＇ writing is a fundamental technology that should be mastered by medical trainee in the course of internship;it is also the practice and examination of the students＇ clinical thinking ability.Improving the quality of history-taking and medical records depends on the pre-position education,and the enforcement of instruction and guiding responsibility.Occasional competitive campaigns are also suggested.

关 键 词：实习生 病史采集 病历书写 

分 类 号：G642.44[文化科学—高等教育学]