某院规培医师入院记录书写质量分析  

Analysis of the Writing Quality of Admission Records Written by Trained Physicians in a Certain Hospital

作　　者：张红卫[1] Zhang Hongwei(Beijing Luhe Hospital Affiliated to Capital Medical University,Beijing 101149,China)

机构地区：[1]首都医科大学附属北京潞河医院,北京市101149

出　　处：《中国病案》2023年第3期22-24,共3页Chinese Medical Record

摘　　要：目的 通过对某院规培住院医师的入院记录进行书写质量分析,为提高住院医师规范化培训质量提供依据。方法 对2022年1月1日-2022年6月30日于某院进行规范化培训的住院医师60人,随机抽取同期每人1份入院记录,根据原国家卫生部印发的病历书写基本规范及某院教学部制定的规范化培训住院医师病案质量检查表进行质控评分。结果 内科规培医师的学历较高,全日制硕士在读研究生占77.78%,全科医学规培医师学历较低,本科毕业生占96.15%;外科规培医师入院记录平均92.24±5.02分,内科平均90.26±4.85分,全科医学平均89.19±4.85分。主要缺陷为遗漏有鉴别意义的阴性症状或症状,缺陷率为30%,家族史描述不规范占28.33%。结论 规培医师病历书写存在不足,应加强规培医师病历书写相关的法律法规培训,加强病历书写能力的培养,以提高住院医师规范化培训质量。Objectives This study aims to provide a basis for promoting the standardized training quality of hospital residents through the quality control analysis of the writing quality of admission records of resident physicians trained in a hospital.Methods For 60 residents who received standardized training in a hospital from January 1,2022 to June 30,2022,one admission record was randomly selected for each person during the same period.The quality control was rated according to the basic norms of medical record writing issued by the former Ministry of Health and the standardized training resident medical record quality checklist formulated by the teaching department of a hospital.Results Physicians trained in internal medicine had relatively high academic qualifications,and 77.78%of them were full-time graduate students.Physicians trained in general practice had relatively low academic qualifications,with undergraduate graduates accounting for 96.15%.The average admission record of surgical doctors was 92.24±5.02,that of internal medicine was 90.26±4.85,and that of general medicine was 89.19±4.85.The main defect was the omission of negative symptoms or symptoms with differential significance.The defect rate was 30%and the description of family history accounted for 28.33%.Conclusions There are some deficiencies in the medical record writing of trained doctors.It should be placed on strengthening the relative training of laws and regulations related to the medical record writing of standardized trainers and strengthening the training of writing ability of medical records,so as to improve the quality of standardized training for residents.

关 键 词：规培医师 入院记录 病案质量 问诊 

分 类 号：R197.3[医药卫生—卫生事业管理]