病历书写培训从形式框架迈向内涵化的教学探索  

Exploration of teaching in medical record writing training:transitioning from formal frameworks to connotative content

作　　者：许杰[1] 陈镁仪 李登[1] 赵敏[1] 王宜 陈样新[3] Xu Jie;Chen Meiyi;Li Deng;Zhao Min;Wang Yi;Chen Yangxin(Department of Orthopedics,Sun Yat-sen Memorial Hospital,Sun Yat-sen University,Guangzhou 510120,Guangdong,China;Department of Continuing Education,Sun Yat-sen Memorial Hospital,Sun Yat-sen University,Guangzhou 510120,Guangdong,China;Department of Internal Medicine-Cardiovascular Medicine,Sun Yat-sen Memorial Hospital,Sun Yat-sen University,Guangzhou 510120,Guangdong,China)

机构地区：[1]中山大学孙逸仙纪念医院骨外科,广东广州510120 [2]中山大学孙逸仙纪念医院继续教育科,广东广州510120 [3]中山大学孙逸仙纪念医院内科,广东广州510120

出　　处：《中国毕业后医学教育》2025年第3期189-193,共5页Chinese Journal of Graduate Medical Education

摘　　要：目的应用电子病历系统对住院医师进行病历书写培训,探索住院医师病历书写培训的新模式,着力住院医师病历书写的内涵提升。方法将中山大学孙逸仙纪念医院骨科专业基地2020年入培的一年级住院医师59人分为教改组(n=31)和传统组(n=28)。教改组进行标准病历示教、对比教学及实际病历书写;传统组进行常规教学活动。培训前后两组分别进行理论测验及病历书写评价。结果培训前教改组与传统组的理论测试成绩和病历书写成绩差异均无统计学意义(均P>0.05)。培训后,教改组相较于传统组在理论测试总成绩和病例分析成绩上得分更高,差异具有统计学意义(均P<0.05)。此外,教改组的病历书写总成绩和入院记录成绩也高于传统组,差异具有统计学意义(均P<0.05)。结论在电子病历系统应用基础上进行病历书写的内涵化教学可以培养住院医师临床思维和独立思考能力,住院医师和指导医师对本方法评价较高,值得临床推广。Objective To apply the electronic medical record system to train resident doctors in medical record writing,explore a new method for resident doctors'medical record writing training,and focus on enhancing the connotation of resident doctors'medical record writing.Methods 59 first-year residents who was enrolled in 2020.in the orthopedic base of Sun Yat Sen Memorial Hospital were divided into teaching reform group(n=31)and control group(n=28).The teaching reform group accepted standard medical record teaching,comparison teaching and actual medical record writing.The control group received routine teaching activities.Theoretical test and medical record writing evaluation were conducted before and after the training.Results The teaching reform group and the control group showed no significant differences in pre-training theoretical test scores and medical record writing scores(all P>0.05).After the training,the teaching reform group scored higher than the control group in the total scores of the theoretical test and case analysis,with statistical significance(all P<0.05).Additionally,the teaching reform group also achieved higher scores in the total medical record writing and admission record writing than the control group,which were also statistically significant(all P<0.05).Conclusion The connotative teaching of medical record writing based on the application of electronic medical record system can promote residents to flexibly use the electronic medical record system and cultivate their ability of independent thinking and clinical thinking.

关 键 词：骨科 住院医师规范化培训 病历书写 电子病历系统 

分 类 号：G40-034[文化科学—教育学原理] R4[文化科学—教育学]