病案首页数据用于儿科住院医师规范化培训诊疗范围评价的可行性探讨  

Feasibility of using the the first page data of medical records to evaluate the treatment scope for standardized residency training in pediatrics

作　　者：宋菲 曾跃萍[1] 吕亚奇 王爱华[1] 倪鑫[1] Song Fei;Zeng Yueping;Lv Yaqi;Wang Aihua;Ni Xin(Beijing Children's Hospital,Capital Medical University,National Center for Children's Health,Beijing 100045,China)

机构地区：[1]国家儿童医学中心,首都医科大学附属北京儿童医院,北京100045

出　　处：《中国毕业后医学教育》2025年第3期161-164,共4页Chinese Journal of Graduate Medical Education

摘　　要：目的探讨病案首页数据用于儿科住院医师规范化培训(简称住培)诊疗范围评价的可行性。方法选取首都医科大学附属北京儿童医院2018年6月至2021年5月75名住院医师,收集同期该院出院患者病案首页的诊断信息进行统计分析。结果该专业基地和住院医师在研究期间有部分病种的收治未达到要求,病种总体达标率为91.7%,符合儿科专业基地标准的要求,住院医师收治病种总体达标率为82.1%。结论病案首页数据可以反映住培基地和住院医师年诊疗范围的数量,为评价提供客观的数据支持。Objective To explore the feasibility of using the data from the first page of medical records to evaluate the diagnosis and treatment range of resident physicians in our hospital's residency training base.Methods 75 resident physicians who enrolled in 2018(from June 2018 to May 2021)were included in this study,and diagnostic information on the first page of medical records of discharged patients from our pediatric training base during the same period was collected for statistical analysis.Results The hospital treatment of some diseases in the base and from the resident doctors did not meet the requirements.The overall rate of meeting the standard of the base was 91.7%,and that of the resident doctors was 82.1%.Conclusion The data on the first page of medical records can reflect the number of annual diagnosis and treatment scope of resident training bases or resident physicians,and can provide objective data support for evaluation.The hospital managers should fully stimulate the subjective initiative of resident physicians and effectively improve the data quality of the first page of medical records.

关 键 词：住院医师规范化培训 儿科 诊疗范围 病案首页 

分 类 号：G40-034[文化科学—教育学原理] R72[文化科学—教育学]