| 临床医生岗前培训中病历书写缺陷分析 |
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| 引用本文： | 谢建英,郑筠,黄妍璇,陈丹霞. 临床医生岗前培训中病历书写缺陷分析[J]. 现代医院, 2005, 5(8): 122-123 |
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| 作者姓名： | 谢建英 郑筠 黄妍璇 陈丹霞 |
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| 作者单位： | 汕头大学医学院第一附属医院,广东汕头,515041 |
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| 摘 要： | 目的加强住院医生及进修医生对病历书写的基本功训练。方法随机抽取我院近两年来由住院医生及进修医生书写的病历600份并进行分析。结果有书写缺陷的病历为312份,缺陷率为52%,其中现病史书写缺陷率最高,为34%。结论住院医生及进修医生应加强岗前培训,重点掌握现病史的采集及描述,以提高病历书写质量。
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| 关 键 词： | 病历缺陷 住院医生及进修医生 岗前培训 |
DISCUSS ON THE NECESSITY OF CLINICIANS'''' PRE-THE-POST TRAINING IN VIEW OF THE MEDICAL HISTORY WRITING DEFECT |
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| Xie Jian-ying,Zheng Yun,Huang Yan-xuan The First Affiliated Hospital of Shantou University Medical College,Shantou,Guangdong Province PRC. DISCUSS ON THE NECESSITY OF CLINICIANS'''' PRE-THE-POST TRAINING IN VIEW OF THE MEDICAL HISTORY WRITING DEFECT[J]. Modern Hospital, 2005, 5(8): 122-123 |
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| Authors: | Xie Jian-ying Zheng Yun Huang Yan-xuan The First Affiliated Hospital of Shantou University Medical College Shantou Guangdong Province PRC |
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| Affiliation: | Xie Jian-ying,Zheng Yun,Huang Yan-xuan The First Affiliated Hospital of Shantou University Medical College,Shantou,Guangdong Province 515041 PRC |
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| Abstract: | |
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| Keywords: | Defect of medical history Resident and advanced training physician Pre-the-post training |
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