电子病历在口腔医学专业本科生临床实习中的应用与思考  

Application and experience of electronic medical record in clinical practice of oral undergraduates

作　　者：黄茜[1,2] 宋锦璘 张丹 马易辉[1,2] 王璐 吴小红 Huang Qian;Song Jinlin;Zhang Dan;Ma Yihui;Wang Lu;Wu Xiaohong(Department of Prosthodontics,The Affiliated Hospital of Stomatology,Chongqing Medical University,Chongqing 401147,China;Chongqing Key Laboratory for Oral Diseases and Biomedical Sciences,Chongqing 401147,China;Department of Orthodontics,The Affiliated Hospital of Stomatology,Chongqing Medical University,Chongqing 401147,China)

机构地区：[1]重庆医科大学附属口腔医院修复科,401147 [2]重庆市重点口腔疾病和生物医学实验室,401147 [3]重庆医科大学附属口腔医院正畸科,401147

出　　处：《中华医学教育探索杂志》2020年第11期1313-1316,共4页Chinese Journal of Medical Education Research

基　　金：重庆市研究生教育教学改革研究立项项目(yjg133039);重庆医科大学口腔医学院教育教学改革研究项目(kqj201404)。

摘　　要：病历书写是口腔医学专业本科生临床实习的重要环节。重庆医科大学附属口腔医院口腔医学本科生实习中,学生会在带教教师的指导下使用电子病历系统。本研究通过调查,分析本科生在实习时电子病历的使用情况,抽查电子病历质量,发现电子病历的使用能够指导实习生提升临床各方面能力;但学生实习中存在依赖病历模板,未能充分调动与培养临床思维等不足。提出通过加强岗前教育、调动学生主观能动性等措施,促进电子病历应用及实习教学质量。Medical record writing is an important part of clinical practice for stomatology undergraduates.The application of electronic medical record system has been used under the guidance of teachers in the practice of stomatology undergraduates in our hospital.This paper investigates the use of electronic medical records of undergraduates in practice through questionnaires,and analyzes the quality of electronic medical records by spot checking.It's found that electronic medical records can guide interns to improve their clinical abilities in all aspects,but there are still some shortcomings such as dependence on medical record templates and inadequate mobilization of clinical thinking ability.This paper puts forward some measures to promote the application of electronic medical records and the quality of practice teaching by strengthening pre-job education and mobilizing students'subjective initiative.

关 键 词：电子病历 口腔医学 本科生 临床实习 

分 类 号：R78[医药卫生—口腔医学]