病历导师制教学方式在病历书写教学中的应用  

The application of the medical record mentorship model in teaching medical record writing

作　　者：张明明 胡永仙[1] 胡春燕[2] 黄河[3] 沈思思 虞朝辉[3] ZHANG Mingming;HU Yongxian;HU Chunyan;HUANG He;SHEN Sisi;YU Chaohui(Bone Marrow Transplantation Center,The First Affiliated Hospital,Zhejiang University School of Medicine,Hangzhou 310003,China;Teaching Department,The First Affiliated Hospital,Zhejiang University School of Medicine,Hangzhou 310003,China;The First Affiliated Hospital,Zhejiang University School of Medicine,Hangzhou 310003,China;Dean s Office,Zhejiang University School of Medicine,Hangzhou 310058,China)

机构地区：[1]浙江大学医学院附属第一医院骨髓移植中心,杭州310003 [2]浙江大学医学院附属第一医院教学部,杭州310003 [3]浙江大学医学院附属第一医院,杭州310003 [4]浙江大学医学院教务处,杭州310058

出　　处：《浙江医学教育》2024年第3期171-174,共4页Zhejiang Medical Education

摘　　要：目的 探讨病历导师制教学方式在病历书写教学中的应用效果。方法 选取2022年4月至2022年9月在浙江大学医学院附属第一医院、浙江大学医学院附属第二医院和浙江大学医学院附属邵逸夫医院进行内科学实习的本校2015级八年制临床医学专业共57名学生作为研究对象。将在浙江大学医学院附属第一医院进行内科学实习的19名学生设为试验组,采用病历导师制教学方式;将在浙江大学医学院附属第二医院和浙江大学医学院附属邵逸夫医院进行内科学实习的38名学生设为对照组,采用传统教学方式。18周内科学实习结束后,采用病历书写标准化考核方式,比较两组学生病历书写成绩的差异,并对试验组学生开展有关病历导师制教学满意度的问卷调查。结果 试验组学生的病历书写考核成绩为(87.34±5.38)分,对照组学生的病历书写考核成绩为(79.64±9.89)分,其差异具有统计学意义(P<0.001);试验组学生对病历导师制教学方式给予高度认可,其病历教学时间、教学内容、教学方式的认可度评分分别为(9.21±0.71)分、(8.53±0.77)分、(8.89±0.66)分。结论 病历导师制教学方式有助于提高医学生的病历书写能力,获得医学生的高度认可,未来值得进一步推广。Objective To explore the effectiveness of the medical record mentorship model in teaching medical record writing.Methods From April 2022 to September 2022,a total of 57 students enrolled in 2015 from the 8-year clinical medicine program of Zhejiang University,who interning in internal medicine of The First Affiliated Hospital,The Second Affiliated Hospital,and Sir Run Run Shaw Hospital,Zhejiang University School of Medicine,were selected as the subjects of the study.A total of 19 students from Department of Internal Medicine,the First Affiliated Hospital,Zhejiang University School of Medicine were included in the experimental group teaching with medical record mentorship model;38 students from Department of Internal Medicine,The Second Affiliated Hospital and Sir Run Run Shaw Hospital,Zhejiang University School of Medicine were included in the control group teaching with traditional model.After 18-week internship in internal medicine,a standardized assessment of medical record writing was used to compare the differences in medical record writing scores between the two groups.A survey was also conducted in the experimental group regarding their satisfaction with the medical record mentorship model.Results The students from the experimental group scored 87.34±5.38,and those from the control group scored 79.64±9.89 on the medical record writing assessment.The experimental group outperformed the control group,and the difference was statistically significant(P<0.001).Students in the experimental group highly recognized the medical record mentorship model,and the ratings(on a 10-point scale)for their satisfaction with the teaching time,content,and methods of the medical record mentorship model were 9.21±0.71,8.53±0.77,and 8.89±0.66,respectively.Conclusions The medical record mentorship mode helps to improve medical students medical record writing ability and is highly recognized by medical students,which is worth further promotion in the future.

关 键 词：病历导师制 病历书写 临床实习 教学方式 医学生 

分 类 号：G642[文化科学—高等教育学] R-05[文化科学—教育学]