病历质控教学法在提高实习生病历书写水平中的作用探讨  

The role of quality control teaching method in improving interns' medical record writing

作　　者：陶春牡[1] 吴玲玉[1] 徐丽芳[1] 

机构地区：[1]靖江市人民医院科教科,江苏靖江214500

出　　处：《中国医学教育技术》2013年第3期359-361,共3页China Medical Education Technology

摘　　要：目的对新来实习生应用病历质控教学法进行住院病历书写教学,探讨其在提高实习生病历书写水平中的作用。方法让新来院实习生对本院自行设计的教学病历进行质量控制、讨论分析,并进行讲评,然后评价实习生病历书写的质量与水平,并观察临床实践能力。结果通过应用病历质控教学法,实习生可以更快掌握住院病历书写,并能大幅度减少缺陷与不足,提高病历质量及临床诊疗能力。结论应用病历质控教学法对实习生进行病历书写教学,对提高实习生病历书写水平具有促进作用,对培养临床诊疗思维具有积极意义。Objective To discuss the role of medical record quality control method in improving new interns＇ medical record writing. Methods New interns were asked to control the quality of self-designed teaching medical records, discuss and analyze them, followed by the teachers evaluation. Then the quality of interns＇ medical record writing was evaluated and their clinical practice ability was observed. Results Application of medical record quality control method could help the interns master hospital medical record writing more quickly, greatly reduce writing defects and shortcomings, improve the quality of medical records, and improve their ability of clinical diagnosis. Conclusion Using medical records quality control method in interns ＇ medical record writing teaching can improve medical record writing of interns and plays a positive role in cultivating their clinical diagnosis and treatment.

关 键 词：病历质控 教学 实习 

分 类 号：G642.0[文化科学—高等教育学]