基础医学与临床 ›› 2011, Vol. 31 ›› Issue (3): 348-350.

• 医学教育 • 上一篇    

医学生外科病历书写教学的特点及对策

朱琳1,邱贵兴2,于健春3   

  1. 1. 中国医学科学院北京协和医学院北京协和医院
    2. 中国医学科学院北京协和医学院北京协和医院骨科
    3. 中国医学科学院北京协和医学院北京协和医院普通外科
  • 收稿日期:2010-06-18 修回日期:2010-07-07 出版日期:2011-03-05 发布日期:2011-03-14
  • 通讯作者: 于健春 E-mail:yu-jch@163.com

The Common Problems And Strategies In The Teaching Of Surgical Medical Records

Lin ZHU1,Gui-xing QIU2,Jian-chun YU1   

  1. 1. PUMC Hospital, CAMS & PUMC
    2. Orthopaedics Department, PUMC Hospital, CAMS & PUMC
  • Received:2010-06-18 Revised:2010-07-07 Online:2011-03-05 Published:2011-03-14
  • Contact: Jian-chun YU E-mail:yu-jch@163.com

摘要: 目的 分析外科病历的特点及医学生书写的常见问题,以提高医学生临床技能,促进外科临床教学。方法 总结912份北京协和医院外科医学生住院病例,分析其常见问题,结合外科病历的特点,提出外科病例书写教学的方法与对策。结果 病历集中体现出一些共性问题,例如现病史与病历特点书写冗长重复,专科查体不完善,拟诊讨论简单、欠缺条理性等。结论 外科病历书写有其独特特点,应详细分析并结合这一特点,以规范性、条理性和完整性的原则指导外科病历书写。

关键词: 病历书写, 教学, 外科

Abstract: Objective Evaluate the specialties of the surgery medical record and the common problems the medical students had in writing it, so as to accelerate the clinic teaching of the surgery department and increase the clinic skills of the students. Methods 912 cases of medical records written by the interns of PUMCH were summarized. The common problems and deficiency were evaluated. Combined with the specialties of surgical medical records, the methods and strategies in surgical medical records teaching are proposed. Results There were some common problems in the 912 cases of medical records. The medical history and case characteristic were tediously long and repeated. The physical examination is incomplete. The diagnosis discussion is too simple and lack of order. Conclusions The writing of surgical medical records has its characteristics, which should be evaluated in detail during the teaching and training of medical students. Combined with these characteristics, the surgical medical records should be taught and written under the rules of standard, ordered and integrated.

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