电子病历系统对医学生临床实践活动的影响  

The Effects of Electronic Medical Record System on the Clinical Practice Activities of Interns

作　　者：吴凡[1] 陈江新 

机构地区：[1]武汉大学人民医院医疗部 [2]武汉市第八医院医务处

出　　处：《中国病案》2012年第10期60-61,共2页Chinese Medical Record

摘　　要：电子病历系统既给医学生了解病史、从知识库中获取相关知识、规范病历的书写、提高阅片能力和按规定完成病历的书写、树立安全的意识、获得经典的诊疗方案、得到同质的教育、保证其实践活动在老师监督下完成提供了方便,也存在无医学生权限、缺乏上级医师审核、影响医学生对检验正常值记忆与前沿知识的掌握、影响医学生医学思辨能力的培养、使写书能力下降等弊端。因此,要采取加强依法执业教育、增设医学生的病历权限、增加查重、逻辑错误判断功能、提高上级医师审阅的能力与水平、进行病历书写、诊断与鉴别诊断书面考试与比赛等形式,消除电子病历系统对医学生临床实践活动的不利影响。Electronic medical record system （EMRS） brings a lot of convenience to the activities of interns, such as acquiring the disease history of the patients, gaining new knowledge, ruling the medical record writing, improving their capacity to read the medical imagery, creating the safety consciousness, gaining the classics programs to diagnose and treat, gaining equal education and complete their practice activities under the supervision of teachers. But there are also many defects, such as no right for students, the deficiency of higher level doctor authorization, influencing their memory of the normal level of checkouts, the learning of leading knowledge, the cultivation of their thinking ability, and decreasing the capacity in hand writ- ing. Therefore, some countermeasures are taken to eliminate the disadvantages of EMRS, such as strengthen the education of working in laws among interns, add the right for students, add the functions to correct and logic check in EMRS, conduct some examinations in hand - writing and diagnosis.

关 键 词：电子病历 医学生 临床实践 影响 

分 类 号：R-4[医药卫生]