终末病历评比对住院医师培养的指导作用

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目的:了解目前住院医师病历书写的质量,考查多年来北京大学人民医院住院医师病历书写的教学效果。方法采用自愿报名和科室推荐相结合的方式,选取北京大学人民医院88名住院医师的176份病历进行评价,分析其中存在的问题。结果病历集中出现一些共性的问题,如关键信息缺失、病程存在抄袭现象、治疗方案笼统等。结论应当从培养临床思维、综合分析能力等多个角度训练低年资住院医师;同时,通过加强语文基础和文化修养培训,提高他们的综合素质,进而提高他们的病历书写能力。“,”Objective Evaluate the teaching effect of the writing of cases of medical records by resident doctors in Peking University People’s Hospital recent years,so as to learn the quality of the cases of medical records written by them recently.Methods 176 cases of medical records of 88 resident doc-tors had been chosen through voluntary signing up and recommended by departments.After that,FAQ’s had been analyzed and the methods and strategies had been put forward.Results There were some com-mon problems in the 176 cases of medical records.Such as the short of the key information,plagiarism of course of the disease,ambiguous treatment plans.Conclusions The importance of cases of medical re-cords increases gradually.The capacity of writing of cases of medical records of resident doctors should be trained from multiple dimensions,such as clinical thinking,ability of comprehensive analysis and etc. Meanwhile,the comprehensive qualities of the resident doctors should be developed by brought up abilities of literature and culture.
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