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| 中文摘要: |
| 目的 对基于导师制的病历书写教学进行探索和研究。方法 导师和规培医师使用评分表，对病历进行双评分，观察指标包括：两个版本评分表在评分时间方面的差异；导师和规培医生评分数值的差异；病历书写扣分分布；实施1年后病历评分的变化趋势。结果 评分数值导师明显低于规培医师（t=8.919，P＜0.05）；病历扣分主要在现病史、体格检查、诊断分析、诊疗计划等方面；实施1年后导师评分呈上升趋势，规培医师评分呈下降趋势。结论 该方法有效提高了病历书写教学质量，提高了规培医师辨识病历书写中存在问题的能力。 |
| 英文摘要: |
| Objective To explore the teaching of medical record writing based on tutorial system. Methods The tutors and residents in standardization training both scored the medical record. The observation indexes included the difference of scoring time between the two editions, the difference of scoring value between tutors and doctors, the distribution of deduction points in medical record writing, and the change trend of medical record score in one year. Results The scoring value of tutors was significantly lower than that of residents undergoing standardization training (t=8.919, P<0.05); the deduction of medical records was mainly in the aspects of history of present illness, physical examination, diagnosis and analysis, and treatment plan. After one year of implementation, the score of tutors increased, while that of residents decreased. Conclusion This method can effectively improve the teaching quality of medical record writing and the ability of residents to discerning problems in medical record writing. |
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