与临床思维相结合的首次病程记录培训方法和效果探析  

Exploration of Training Methods and Effects for Initial Medical Record Documentation Combined with Clinical Thinking

作　　者：黄涛 林晓英 陆楠 马兆垠 李芳邻 Huang Tao;Lin Xiaoying;Lu Nan;Ma Zhaoyin;Li Fanglin(Shandong University Qilu Medical School Medical Integration and Practice Center;Shandong University Second Hospital;Shandong University Qilu Hospital,Jinan 250012,Shandong,China)

机构地区：[1]山东大学齐鲁医学院医学融合与实践中心 [2]山东大学第二医院 [3]山东大学齐鲁医院,山东济南250012

出　　处：《中国高等医学教育》2024年第9期128-129,131,共3页China Higher Medical Education

基　　金：山东省本科高校教学改革研究项目(M2021345,Z2022164);山东大学本科教育教学改革研究项目(2023Y336);山东大学教师思想政治和师德师风建设专项课题(SDJGZP202313,SDJGYL202315);山东大学齐鲁医学院本科教学改革研究项目(qlyxjy-202331,202347)。

摘　　要：首次病程记录的书写质量反映了医生对疾病的综合分析和处置能力.通过不同指导方式对实习医生首次病程记录进行培训,将病历修改纳入常规临床教学实践评价,能有效提高医学生病历记录书写质量,提升医学生临床综合思维能力和人文化医患沟通能力.To explore the effectiveness of training methods for initial medical record documentation when combined with clinical thinking,and to assess their impact on the quality of medical record writing.This study involved training for interns on initial medical record documentation using different guidance methods.The training incorporated regular clinical teaching practices and evaluations of medical record modifications.The quality of medical records and the interns'abilities in clinical comprehensive thinking and patient communication were assessed.The training methods that integrated clinical thinking significantly improved the quality of medical records,enhanced the interns'comprehensive clinical thinking abilities,and improved their humanistic communication skills with patients.Incorporating clinical thinking into the training for initial medical record documentation effectively enhances the writing quality of medical records,and contributes to better clinical thinking and patient communication skills among medical students.

关 键 词：首次病程记录 临床思维 岗位胜任力 

分 类 号：G642.0[文化科学—高等教育学]