规范实习生出院记录书写的实践与思考

目的：探讨实习生书写出院记录对提高实习效果的意义.方法：对2007年来我院临床实习本科生83人,通过对出院记录书写进行专题培训、制订出院记录考核评分标准、随机检查出院记录纳入实习生出科考核等措施,规范实习生书写出院记录.实习结束时按常规进行理论及操作考试.结果：07年实习生出院记录的评分较06年明显提高（P〈0.05）,07年病史采集和病例分析的考核成绩较06年显著提高.结论：规范书写出院记录有助于提高实习效果.

The standard intern leaves the hospital the record writing practice and ponders

Objective： Discusses the intern writing out of hospital record to enhance the practice effect the significance. Methods： To 2007 my courtyard clinical practice undergraduate student 83 people,through carries on special training, the making out of hospital record inspection grading standard,the stochastic inspection out of hospital record to out of hospital record writing integrates the practice to give birth measures and so on branch inspection, standard intern writing out of hospital record. When practice conclusion carries on the theory and the operation test according to the convention. Results： 07 years intern leaves the hospital the record grading for 06 years obviously to enhance the inspection result 06 year remarka- ble enhancement which （P〈0.05） ,07 year medical history gathering and case of illness analyze. Conclusion： The standard writing out of hospital re- cord is helpful to the enhancement practice effect.