病程记录书写中的常见错误与改进建议  

The common mistakes and recommendations in writing progress note

作　　者：李澄宇[1] 李小维[1] 叶子冠[1] 许浦生[1] 徐米清[1] Li Chengyu;Li Xiaowei;Ye Ziguan;Xu Pusheng;Xu Miqing(Teaching and Research Section of Medicine,The Second Affiliated Hospital of Guangzhou Medical University,Guangzhou 510260,China)

机构地区：[1]广州医科大学附属第二医院内科学教研室,广州510260

出　　处：《中华医学教育杂志》2019年第5期367-370,共4页Chinese Journal of Medical Education

摘　　要：如何书写合格的病程记录是每个年轻医师必须面对的问题,也是临床工作中比较容易犯错的部分。其常见错误主要表现在书写病程时缺乏分析、照搬照抄、信息丢失、理解错误和记录不按时等。造成错误的原因既有轻视心理、懒惰思想等主观问题,也有基础薄弱、缺乏指导、工作负担重等客观因素。因此,建议从端正心态、勤学多问、加强指导、合理减负等几方面加以纠正,以不断提高年轻医师的病程记录书写质量。Writing progress note accurately has been challenging for new residents.The most frequently seen mistakes including lacks of analyzing,copying blindly,incomplete information recording,misinterpretation of instructions from supervisors and delayed recording.The causes of these mistakes varied.On one hand,there are subjective reasons that the residents underestimated its importance or lacking motivations to do it well.On the other hand,objective reasons are also common such as weak medical knowledge comprehension,lack of supervision and overburdened in work.To resolve these problems,there are some recommendations would be helpful,which are to educate for correct motivation,to encourage them to be diligent and inquisitive,to supervise them with more instructive advices and to reduce their workloads reasonably.

关 键 词：病程记录 错误 建议 

分 类 号：R-05[医药卫生]