肺结节结构化电子病历在住院医师规范化培训中的应用  

Application of structured electronic medical records for pulmonary nodules in standardized training of resident physicians

作　　者：石思恩[1] 于修义[1] 范晟 耿国军[1] 姜杰[1] SHI Si’en;YU Xiuyi;FAN Sheng;GENG Guojun;JIANG Jie(Department of Thoracic Surgery,The First Affiliated Hospital of Xiamen University,Xiamen,361003,Fujian,P.R.China)

机构地区：[1]厦门大学附属第一医院胸外科,福建厦门361003

出　　处：《中国胸心血管外科临床杂志》2022年第6期703-710,共8页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

基　　金：厦门市医疗卫生项目(3502z20199168)。

摘　　要：目的分析肺结节结构化电子病历是否有助于住院医师规范化培训学员(住培学员)掌握肺结节患者的门诊和住院管理能力。方法本研究纳入2018年1月—2021年1月在厦门大学附属第一医院外科住院医生规范化培训基地接受培训的120名学员,其中男94人、女26人,年龄22~31(26.45±2.81)岁。随机分为两组,分别使用我科设计的肺结节结构化电子病历(结构化组)和外科通用非结构化电子病历(非结构化组),分析比较两组学员在住院病历撰写时间、首次病程记录完成时间、病程记录的病历质量、开具入院医嘱的准确率、进行教学查房的质量、患者满意度等方面的差异。结果(1)结构化组住培学员住院病历撰写时间显著短于非结构化组[(53.61±8.12)min vs.(84.25±16.09)min,P<0.010];同样,结构化组首次病程记录完成时间短于非结构化组,且差异有统计学意义[(13.20±5.43)min vs.(27.51±8.62)min,P<0.010]。(2)结构化组学员教学查房质量评分总体显著高于非结构化组,且差异有统计学意义[(84.21±15.61)分vs.(70.91±12.28)分,P<0.010]。(3)结构化组学员病历书写质量评分显著高于非结构化组,且差异有统计学意义[(80.25±9.22)分vs.(74.22±5.40)分,P<0.010]。结论肺结节结构化电子病历在外科住院医师规范化培训中能有效提高培训效果,提高学员处理肺结节的临床业务能力,提高学员采集关键临床数据的完整性和准确性,改善医患关系。Objective To analyze the value of structured electronic medical records for pulmonary nodules in increasing the ability of outpatient service and hospital management by resident physicians.Methods We included 40 trainees[94 males and 26 females aged 22-31(26.45±2.81)years]who were trained in the standardized training base for surgical residents in our hospital from January 2018 to January 2021.The trainees were randomly divided into two groups including a structured group using the structured electronic medical record for pulmonary nodule and an unstructured group using unstructured electronic medical record designed by our department.The time of completing hospitalization records and first-time course records,the quality of course records,the accuracy of issuing admission orders,the quality of teaching rounds,and patient’s satisfaction between the two groups were analyzed and compared.Results(1)The average time in the structured group to complete inpatient medical records was significantly shorter than that of the unstructured group(53.61±8.12 min vs.84.25±16.09 min,P<0.010);the average time in the structured group to complete the first-time course record was shorter than that of the unstructured group(13.20±5.43 min vs.27.51±8.62 min,P<0.010),and there was a significant statistical difference between the two groups.(2)The overall teaching round quality score of the students in the structured group was significantly higher than that in the unstructured group(84.21±15.61 vs.70.91±12.28,P<0.010).(3)The score of the medical record writing quality of the structured group was significantly higher than that of the unstructured group(80.25±9.22 vs.74.22±5.40,P<0.010).Conclusion The structured electronic medical record specific for pulmonary nodules can effectively improve the training efficiency in the standardized training of surgical residents,improve the clinical ability to deal with pulmonary nodules,improve the integrity and accuracy of key clinical data collected by students,and improve doctor-patient

关 键 词：住院医师规范化培训 肺结节 结构化电子病历 临床教学 病历书写 

分 类 号：R-4[医药卫生] C975[经济管理—劳动经济]