摘要
通过对临床医学专业实习医生书写入院病历的实时修改和匿名修改两种教学指导模式的效果观察,研究显示经过半年训练,实习中期书写的住院病历的质量明显好于实习初期,病历中与临床思维相关的内容如现病史、摘要等的改善,实时修改组明显优于匿名修改组。将病历修改纳入常规教学实践评价更有助于提高临床知识的广度和思维分析能力。
Through the observation of the effect of the two teaching modes of real-time modification and anonymous modification in the writing of admission medical records by clinical medical interns,the results showed that the quality of inpatient medical records written in the middle of the internship was significantly better than that in the early stage of the internship during half a year of training,and the improvement of the contents related to clinical thinking such as current medical history and abstract in the medical records were significantly improvement in the real-time modification group than that in the anonymous modification group.Putting the revision of medical records into the routine teaching practice is more helpful to improve the breadth of clinical knowledge and the ability of clinical thinking in medical interns.
作者
黄涛
张斌
杨金玲
臧绍蕾
袁芳
孟晓慧
李芳邻
Huang Tao;Zhang Bin;Yang Jinling(School of Medicine,Shandong University;Qilu Hospital,Shandong University,Jinan 250012,Shandong,China)
出处
《中国高等医学教育》
2021年第7期66-67,83,共3页
China Higher Medical Education
基金
山东大学教育教学改革研究项目(2019Y246,2020Y122,2021Y133)
山东大学齐鲁医学院本科教学改革研究项目(qlyxjy-201711,qlyxjy-201735,qlyxjy-201736,qlyxjy-202015)
关键词
临床医学
病历
思维能力
培养
Clinical medicine
Medical record
Thinking ability
Cultivate
