医学本科生在手外科轮转期间的入院记录质量分析

手外科的病历由于其特殊的发病过程和局部解剖知识的运用,一般轮转医师在书写时难度较大。分析了本科生在手外科轮转期间书写的入院记录346份,缺陷主要表现在现病史和专科检查中描述的不详细和不确切。加强对轮转医师的培训与管理,督促主治医师和科主任的带教与管理职责并强化考核奖惩制度是提高病历质量的主要措施。

Quality Analysis of Admission Records Written By Medical Undergraduates Rotating in Hand Surgery Department

Writing a medical record of hand surgery challenges rotating physicians a lot due to its special pathogenic process and application of regional anatomy knowledge. This article analyzed 346 admission records written by undergraduates rotating in hand surgery department. Defects of these medical records were mainly shown as lack of detailed and exact description of history of present illness and specialist examination. Strengthening the training and management of rotating physicians, supervising the teaching and management responsibility of attending physicians and department chief as well as enhancing evaluation and rewards and punishment system are main measures to improve quality of medical records.