电子病历系统对临床医学生实习的影响及对策

电子病历系统由于其强大的数据库功能及模板功能,便于初入临床的学生熟悉和掌握,可以及早进入临床工作角色,规范临床实践活动,提高自我学习能力;但却容易使学生淡化责任感意识,忽视临床基本功及临床思维的训练。需要通过强化实习生责任意识教育,完善或升级电子病历系统,强化手书病历训练以及调整考核重点等措施保证医疗安全及实习质量。

Influence of Electronic Medical Record System to Internal Medicine Practice of Medical Students

Electronic medical record system, the inevitable outcome of the rapid development of medical informationization,has powerful function of data base and templates, which make it easy for the fresh medical students in practice to study by themselves and adapt to the medical work as soon as possible. It is also convenient to make the students＂ clinical practice standard. Meanwhile, electronic medical re- cord system has some disadvantages in the establishment of consciousness of responsibility, training of medical basic skill and clinical thoughts. Certain interventions, such as consciousness of responsi- bility education, electronic medical record improvement, case history written by hand and test point adjustment, should be used to warrant the medical safety and practice quality.