临床医学专业实习生书写血液科病历的常见问题与对策  

Common problems and countermeasures of clinical medical interns＇ writing medical records in the department of hematology

作　　者：窦红菊[1] 朱虹[2] 庄衍[1] 杨柳[3] 朱琦[1] 陈元美[2] Dou Hongju;Zhu Hong;Zhuang Yah;Yang Liu;Zhu Qi;Chen Yuanmei(Hematology Department,Shanghai Ninth People＇s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China;School of Clinical Medicine,Shanghai Ninth People＇s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China;Medical Records Quality Control Department of Medical Service Section,Shanghai Ninth People＇s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200011,Chin)

机构地区：[1]上海交通大学医学院附属第九人民医院血液内科,200011 [2]上海交通大学医学院附属第九人民医院临床医学院,200011 [3]上海交通大学医学院附属第九人民医院医务处病历质控科,200011

出　　处：《中华医学教育探索杂志》2018年第7期737-741,共5页Chinese Journal of Medical Education Research

摘　　要：为提高临床医学专业实习生书写血液科病历的质量，考核评价100份实习生书写的血液科病历后发现：现病史、既往史、个人史及血液科临床操作、输血、化疗病程记录书写存在的缺陷，是影响血液科实习生病历书写质量的主要原因；临床实习中不重视病历书写、教学管理相对滞后、血液科疾病的特殊性及法律意识淡薄等因素，也是导致病历书写质量不高的原因。因此加强教学管理。提高临床带教教师的综合素质，对实习生进行病历书写的岗前培训，培养实习生的问诊及医患沟通能力，利用血液科的典型病历结合讨论等多种途径；以加强实习生的临床病历书写技能和法律意识，不断提高其病历书写质量。In order to improve the quality of medical records written by interns of clinical medicine in hematology department, we evaluated and analyzed 100 medical records written by the interns. The main reasons that affect the quality of medical record written by interns are the writing defects that are history of present illness, past history, personal history, the record of the clinical operation, blood transfusion and chemotherapy. There are other reasons for affecting the quality of medical records, such as students in clin- ical practice not paying attention to the writing of medical records, the relative lag of teaching management, the particularity of the diseases in the department of hematology and the weak legal consciousness. Therefore, we should strengthen the teaching management, improve the comprehensive quality of the clinical teach- ing teachers, carry out the pre job training of the medical records for the interns, train the interns＇ inquiries and the ability to communicate with the doctors and patients, and make use of the typical medical records of the Department of Hematology to combine the discussion and other ways, so as to strengthen the interns＇ clinical disease writing skills and legal consciousness as well as the quality of their writing medical records.

关 键 词：临床医学专业实习生 血液科 病历书写质量 

分 类 号：R55[医药卫生—血液循环系统疾病]