初学者主诉书写错误的原因分析

目的：通过案例作业发现初学者主诉书写的常见错误并进行调查研究。方法选取2013年9月~2015年6月初次学习主诉和现病史的本科医学生观看视频案例书写的主诉作业作为研究对象，选取美剧《豪斯医生》第五季第9集作为视频素材。按照统一的评判方法判别作业中主诉书写的错误类型并进行统计。结果收到有效作业807份，完全正确的主诉仅15份，占总数的1.8%，基本正确的占总数42%。主症判断不准确、时间不正确、主诉和现病史不一致和术语不规范是初学者主诉书写中最容易犯的4类错误，分别占51%、43%、42%、30%。结论初学者对主诉的书写掌握情况欠佳，通过调查发现了具体的犯错原因，有利于在主诉教学上有的放矢。

The Investigation on the Common Errors of the Chief Complaint Written by Novices

Objective To investigate the common errors made by novices on the chief complaint through case-based assignment. Methods Undergraduate novices from September 2013 to June 2015 wrote the chief complaint through the case of House M.D. (Episode 9 of the fifth season). The type of errors occurring in the assignment was judged by unified distinguish method, and then the data was collected and analyzed. Results 807 available assignments were received, while only 1.8% (15) of the chief complaints were totally correct,42% is basically correct. The mistakes can be classified into 4 types: the wrong primary symptom judgement, the wrong time, the mismatching of the chief complaint and the history of present illness, and un-standard medical terms, which is accounted for 51%, 43%, 42%, 30%, respectively. Conclusion The novices have poor writing situation on the chief complaint. The cause of the errors of the chief complaint written we researched can be the guidance to make a promotion in the teaching.