住院医师病历书写质量和抢救休克能力现状的调查与思考  

The investigation and thinking of the status quo of the residents in medical record writing and shock treatment

作　　者：左鹏[1] 胡维琨[2] 万宝俊[3] 余慕清 赵建平[1] 熊盛道[1] 

机构地区：[1]华中科技大学同济医学院同济医院内科诊断学教研室呼吸与危重症医学科,武汉430030 [2]华中科技大学同济医学院同济医院内科诊断学教研室眼科,武汉430030 [3]华中科技大学同济医学院同济医院内科诊断学教研室第二临床学院,武汉430030

出　　处：《中华诊断学电子杂志》2015年第4期32-35,共4页Chinese Journal of Diagnostics(Electronic Edition)

基　　金：华中科技大学教学基金(13086);华中科技大学同济医院教学基金

摘　　要：目的：探讨目前住院医师书写病历质量及抢救休克能力的现状，为进一步提高住院医师书写病历内涵质量和抢救休克的能力，同时为临床教学改革提供必要的依据。方法通过对185名内科住院医师进行①书写主诉、现病史和②休克处理两个技能的考核，以正确与不正确作为判断标准，计算不正确率。结果185名住院医生中，进修生、规培生、留校生主诉书写不正确率分别94．4％、60．0％、78．3％，总不正确率高达88．6％，3组比较差异有统计学意义（χ2＝23．39， P＜0．01）；进修生与规培生、留校生比较，均差异有统计学意义（χ2＝19．56，5．03；P＜0．05）。现病史各项平均不正确率达54．7％，其中在起病诱因、主要症状变化和伴随症状方面，进修生、规培生、留校生总不正确率分别为92．4％、82．7％和42．2％，3组差异有统计学意义（χ2＝27．08，17．11，13．38；P＜0．01）。在起病诱因方面不正确率进修生（97．2％）与规培生（65．0％）比较，差异有统计学意义（χ2＝23．83， P＜0．01）；在主要症状变化方面不正确率进修生（88．7％）与规培生（55．0％）、留校生（69．6％）比较，差异有统计学意义（χ2＝12．81，4．57， P＜0．05）。休克抢救措施各项平均不正确率平均高达52．1％，其中如何吸氧与生命体征监测、建立静脉通道的原则和方法、如何补充血容量、如何纠正酸碱与水电平衡和如何选择药物治疗5个方面的总不正确率分别为46．5％、79．5％、42．7％、47．6％和44．3％。如何吸氧与生命体征监测方面，进修生为45．1％，其与规培生（55．0％）、留校生（47．8％）的不正确率差异无统计学意义（χ2＝0．70，0．06；P＞0．05）；建立静脉通道的原则和方法方面不正确率最高者为进修生外，如何补充血容量、如何纠正酸碱与水电平衡�Objective In order to further promote the abilities of medical records writing and the ability of shock rescue in the residents,meanwhile provide an evidence for the reform of clinical teaching,we investigated these abilities of the residents in current situation. Methods Two skills of 185 physician residents were evaluated：one was the writing of complaint and present history,the other was the treatment of shock.The result of the evaluation was descriped as correct or incorrect,with the incorrect rate calculated. Results Among 185 residents,the incorrect rates of complaint writing were 94.4%,60.0% and 78.3% for the training doctors, the normative training doctors and the native doctors graduated doctors from our own＆amp;nbsp;medical school respectively. The total incorrect rate was 88. 6%, the differences among those three groups showed statistical significance （χ2= 23. 39, P 〈0. 01）;there were also significant differences between the training doctors and the normative training doctors,and the native doctors （ χ2=19.56,5.03;P〈0.05）.The average incorrect rate of the present history writing was 54.7%.In consideration of the aspects of precipitating factors,such as main symptoms and accompanying symptoms,the total incorrect rates were 92.4%,82.7%and 42.2% for the three groups respectively. There were significant differences among those three groups in each aspect （ χ2=27.08, 17. 11, 13. 38; P 〈0. 01 ） . In the aspect of precipitating factors, the differences between the training doctors （ 97. 2%） and the normative training doctors （ 65. 0%） was significant （ χ2=23.83, P〈0.01）;in the aspect of main symptoms,the differences between the training doctors （88.7%） and the normative training doctors （ 55. 0%） or the native doctors （ 69. 6%） were also obviously （ χ2=12. 81, 4.57;P〈0.05）.The average incorrect rate of shock treatment was 52.1%.In the aspects of oxygen inhaling and vital sign monitoring, intravenous access obtaining, blood volume supplying, pH and elec

关 键 词：心理图像 规范培训 教学评估 

分 类 号：R197.32[医药卫生—卫生事业管理]