基于放射诊断报告规范化书写培训提升放射科住院医师报告书写能力的研究  

Enhancing the imaging diagnostic report quality of radiology residents based on the standardized radiological diagnostic report training

作　　者：史玉书[1] 张瑞[1] 虞丹萍[1] 李志[1] 黄强[1] 肖文波[1] 楼海燕[1] Shi Yushu;Zhang Rui;Yu Danping;Li Zhi;Huang Qiang;Xiao Wenbo;Lou Haiyan(Department of Radiology,the First Affiliated Hospital,College of Medicine,Zhejiang University,Hangzhou 310003,Zhejiang,China)

机构地区：[1]浙江大学医学院附属第一医院放射科,浙江杭州310003

出　　处：《中国毕业后医学教育》2025年第3期194-197,共4页Chinese Journal of Graduate Medical Education

基　　金：浙江大学附属第一医院教育教学改革项目(zyjg202214,zyjg202204)。

摘　　要：目的评估诊断报告规范化书写训练在提升住院医师报告书写能力方面的作用和价值。方法将40名不同年级的放射科专业住院医师纳入研究,在培训前后分别独立进行影像诊断报告书写,隐藏报告的临床资料和报告书写医生后,由4名放射科主治医师再次阅片,并依据《放射诊断报告质量评分标准》进行评分。比较培训前后住院医师影像诊断报告质量评分/等级差异。结果培训后,住院医师的报告质量评分和报告质量等级均明显提高,差异有统计学意义(均P<0.05)。结论放射诊断报告规范化书写训练可有效提高放射科专业住院医师的报告书写能力。Objective To evaluate the role and value of the standardized radiological diagnostic report training in improving resident's writing ability.Methods Forty radiology residents of different grades were included in the study.They independently wrote imaging diagnostic reports before and after the training.The clinical information of the reports and the names of radiologists were concealed.Four attending radiologists scored the imaging reports before and after the training based on the Quality Scoring Standards for Radiological Diagnostic Reports after diagnosing.The differences in quality scores/grades of imaging diagnostic reports before and after training were analyzed using t-tests.Results After training,the quality scores and grades of the residents'reports were significantly improved,with statistically significant differences(all P<0.05).Conclusion The standardized radiological diagnostic report training can effectively enhance the writing skills of radiology residents.

关 键 词：医学影像诊断报告 报告规范化书写培训 住院医师规范化培训 

分 类 号：G40-034[文化科学—教育学原理] R445[文化科学—教育学]