内分泌科实习医学生的病案书写缺陷分析  

Defect Analysis of Medical Records Written by Endocrinology Medical Interns

作　　者：曹雪霞[1] 孙丽娜[1] 马雅辉[1] 穆志静[1] Cao Xuexia;Sun Li＇na;Ma Yahui;Mu Zhijing

机构地区：[1]首都医科大学宣武医院内分泌科,北京市100053

出　　处：《中国病案》2018年第6期72-75,共4页Chinese Medical Record

摘　　要：目的分析实习生病案书写的缺陷并提出提高书写质量的对策。方法选择2016年9月-2017年7月期间某院内分泌科实习医学生书写的182份2型糖尿病的纸质病案,其中修改前、后各91份;收集由学生实名填写的病历书写质量的调查问卷91份。运用描述性统计方法对91份病案进行评价,并采用卡方检验分析方法对比修改前后的病案;对91份调查问卷的影响病历书写因素进行Logistic回归分析。结果出现缺陷最多的书写项目是现病史,占65.9%,最少的是辅助检查,占9.9%;修后的书写质量除其他病史、诊断分析和首次病程记录三项外均有明显的提高,P<0.05。其中,改进后的现病史书写项目的无缺陷率由34.1%提升到70.3%;影响现病史项书写质量的主要因素包括"是否主动学习病历书写方面的知识"和"对病历书写质量的考核是否满意"。结论现病史书写最容易出现缺陷,要提高诊断分析等病历项目书写质量,需要增加更多的临床经验。学生没有意识到病历书写的重要性,学习主动性有待提高;实习考核还需加强。Objective This paper aims at analyzing defects of writing medical records（MRs）and improving the quality of writing MRs.Methods 182 MRs（the original records：91,and the modified ones：91）,written by the interns from September 2016 to July 2017 at a certain Hospital,were collected and analyzed via tools of descriptive statistics and chi-square test.Factors affecting the writing MRs in 91 questionnaires filled out by the interns were also analyzed through logistic regression technique.Results Finding showed that the highest defect percentage（65.9%）is allocated to history of present illness（HPI）and the lowest percentage（9.9%）is auxiliary examination.The writing quality of items except three ones,-other history of illness,diagnostic analysis,and initial course taking（their p-values are more than 0.05）-,were improved significantly.Especially,non-defect percentage of HPI increases from 34.1% to 70.3%.The two factors may affect the quality of writing HPI were＂whether the students actively learn the knowledge of writing MR＂and＂satisfaction of evaluation on the quality of writing MR＂.Conclusion Maximum probability of defects is writing HPI.Improving quality of writing MR needs increase in extensive clinical experience.Students are not aware of the importance of writing MR,and their learning initiative should be improved.Additionally,practice evaluation on writing MR needs to be enhanced.

关 键 词：病案 缺陷分析 现病史 2型糖尿病 

分 类 号：G642[文化科学—高等教育学] R-4[文化科学—教育学]