儿科实习医师病历书写缺陷与对策  

Analysis of pediatric interns＆#39; writing defects of medical records and countermeasures

作　　者：付宏 聂勋梅 

机构地区：[1]重庆市江津区中心医院儿科,402260

出　　处：《中华医学教育探索杂志》2014年第9期920-923,共4页Chinese Journal of Medical Education Research

基　　金：重庆市临床重点专科建设项目（渝卫2012-143）

摘　　要：为了提高儿科实习医师病历书写质量，分析535份儿科实习医师病历缺陷后发现：现病史、体格检查及个人史的书写缺陷是影响儿科实习医师病历书质量的主要原因。师资水平不高、教学管理滞后、儿科实习的特殊性及学生在校训练缺乏等因素导致病历书写的不足。由此建议，应重视师资建设，激发教师工作积极性，培养其具备认真负责的工作态度、具有扎实的临床及教学基本功、能合理运用多种教学方法。加强教学管理，多种手段提高实习医师临床思维及文字表达能力。建立健全实习医师病历质量控制体系。合理实施岗前培训及入科教育，增强实习医师法律观念、端正其实习态度、帮助其尽快适应儿科实习环境。注重培养实习医师问诊、查体及医患沟通技能。同时，需改革在校教育，以适应临床发展。In order to improve the quality of medical record written by pediatric interns, the defects of 535 medical records written by pediatric interns were analyzed. The main reasons affecting the quality of medical record written by pediatric interns were found： writing defects among history of present illness,physical examination and personal history. At present, many factors have caused the deficiencies of medical record writing, such as the factor of low-level teachers, the lag of the teaching management, the particularity of pediatric practice, and students＆#39; lack of training in school. So some countermeasures have been suggested：firstly, importance should be attached to the construction of the teaching staff. Measures should be taken to inspire the teachers to work more actively with a serious and responsible attitude. With a solid clinic and teaching skills, teachers can use a variety of methods properly. The management of teaching should be enforced. A variety of means can be used to improve the interns＆#39; clinical thinking and language expression ability , to establish and improve the medical quality control system of the interns constantly, to make use of pre job training and education reason-ably, to strengthen the intern＆#39;s legal ideas, to straight their internship attitude, and to help them to adapt to the pediatric practice environment as soon as possible. At last, measures should be taken to cultivate interns＆#39; interrogation, physical examination and patient communication skills actively and reform the school education to meet the needs of clinical development as well.

关 键 词：儿科教学 实习医师 病历缺陷 

分 类 号：R72[医药卫生—儿科]