住院医师规范化培训中眼科病历书写情况的现状及对策研究  

Research on the Current Situation and Countermeasures of Ophthalmology Medical Records Writing During Standardized Training for Resident Physicians

作　　者：张露 王永晶 程宇芳 郑奕君 项奕[1] ZHANG Lu;WANG Yongjing;CHEN Yufang;ZHENG Yijun;XIANG Yi(Department of Ophthalmology,the Central Hospital of Wuhan,Tongji Medical College,Huazhong University of Science and Technology,Wuhan Hubei 430014,China)

机构地区：[1]华中科技大学同济医学院附属武汉中心医院眼科,湖北武汉430014

出　　处：《中国继续医学教育》2025年第7期153-157,共5页China Continuing Medical Education

基　　金：武汉市中心医院2023年度院级科研项目(23YJ23)。

摘　　要：目的探讨住院医师规范化培训中眼科病历书写情况的现状及应对策略。方法选取2023年7—10月华中科技大学同济医学院附属武汉中心医院眼科的住培医师书写的病历118份,并由参与院内住培的带教老师对这118份已出院待归档病历进行评阅。将病历书写问题分为11大类,统计分析各问题占比并给出反馈意见。结果在118份病历中,存在问题11大类、215项,排名前三的问题分别为上级医师查房(35.3%)、首次病程记录(12.1%)、个人史(11.6%)。结论眼科住培医师病历书写存在多种问题,主要有住培医师眼科专科知识薄弱、态度不端正、医疗文书烦琐等,需要加强住培师资建设,提升住培医师法律法规意识及专科技能,同时优化病历书写流程。Objective To explore the current situation in ophthalmology medical records writing during the standardized training for resident physicians and coping strategies.Methods A total of 118 medical records written by resident physicians in the department of ophthalmology,the Central Hospital of Wuhan,Tongji Medical College,Huazhong University of Science and Technology from July to October 2023 were collected.These 118 medical records of discharged patients awaiting filing were reviewed by physicians who participated in the hospital’s residency training for resident physicians.The problems in medical records writing were divided into 11 major categories,and the proportion of each problem was statistically analyzed,and feedback was given.Results Among the 118 medical records,there were 11 major categories and 215 items of problems.The top three problems were ward rounds by senior physicians(35.3%),the first course of disease(12.1%),and personal history(11.6%).Conclusion There are various problems in the writing of medical records by resident doctors in the ophthalmology department.These mainly include the weak specialized knowledge of ophthalmology among resident physicians,improper attitude,and the complexity of medical documents.It is necessary to strengthen the construction of residency training faculty,improve the awareness of laws and regulations and and specialized skills of resident physicians,and optimize the medical records writing process.

关 键 词：住院医师规范化培训 医疗文书 眼科 病历书写 临床医学 岗前培训 

分 类 号：G642[文化科学—高等教育学]