综合医院全科医学科住院病历书写模式的探讨  

Patterns for general practitioners to write medical records of hospitalizations in general hospitals

作　　者：周凤丽[1] 李玉萍[2] 刘小云[1] 刘玲玲[1] 张海燕[1] 陈宣蓉[1] 江玮[1] 张扣兴[1] ZHOU Fengli;LI Yuping;LIU Xiaoyun;LIU Lingling;ZHANG Haiyan;CHEN Xuanrong;JIANG Wei;ZHANG Kouxing(Department of General Practice,the Third AJjlliated Hospital of Sun Yat-sen University,Guangzhou,Guangdong 510630,China;Transplanlation ICU,Lingnan Hospital,the Third Affiliated Hospital of Sun Yat-sen University,Guangzhou,Guangdong 510630,China)

机构地区：[1]中山大学附属第三医院全科医学科 [2]中山大学附属第三医院岭南医院器官移植ICU,广东广州510630

出　　处：《中国毕业后医学教育》2020年第6期556-560,共5页Chinese Journal of Graduate Medical Education

摘　　要：基于国务院关于加强全科专业住院医师规范化培训基地建设,提高全科医生培养质量的要求,中国各大综合医院均设立了全科医学科。为了体现综合医院全科医学科住院病历的全科特色,体现"以人为中心、以家庭为单位、以社区为范围,以预防为导向"的全科理念,中山大学附属第三医院自创设计了综合医院全科医学科住院病历书写模板,旨在体现全科的慢性病全程管理理念和针对未分化疾病跨学科的宽而广的全科思维,体现"生物-心理-社会"医学模式。经过全科医学科病房试行,效果佳。主要注重在入院记录、出院记录、出院医嘱、首次病程记录的诊疗计划以及病程记录中体现全科管理理念。Based on the requirements of the State Council to strengthen the construction of standardized training bases for general practitioners and improve the training quality of general practitioners, general practice has been set up in major general hospitals in China. In order to reflect the characteristics of general-practice medical records of inpatients in these hospitals, and embody the idea of " being human-centered, family-targeted, community-oriented, and prevention-guided", a template for writing medical records of inpatients was designed by our hospitaland has been used in general practice in large general hospitals. Such design was intended to embrace the concept of whole-course management of chronic diseases and the open thinking method for diseases with unknown diagnosis. As a health care model of " biology-psychology-society, this template has been well received by focusing on the medical record upon admission, doctors’ instructions, discharge record, diagnosis and treatment plans in the first course of medical records, and each course of medical records.

关 键 词：综合医院 全科医学科 住院病历 全科理念 

分 类 号：G40[文化科学—教育学原理] R5[文化科学—教育学]