标准化病人问诊培训对儿科实习医生病历书写质量的影响分析

目的 探讨标准化病人(standardized patient,SP)问诊培训对儿科实习医生病历书写质量的影响.方法 将160名五年制临床医学专业实习医生分为实验组和对照组,教师采集典型病案,对实验组实习医生进行6次教师模拟SP的问诊培训,即采取教师模拟患儿家长、实习医生向教师询问病史的方法进行问诊培训.培训后教师进行总结,指出实习医生在问诊方面的优点和缺点.对照组实习医生不进行SP问诊培训.最后对两组实习医生书写的病历进行统一评分及比较.结果 实验组实习医生病历书写总成绩高于对照组;实验组实习医生书写的病历在格式、现病史、既往史、个人史、家族史、诊断和鉴别诊断等方面的单项评分也高于对照组.结论 SP问诊培训能够提高儿科实习医生问诊的完整性,使实习医生的思路明确,培养了实习医生与患儿家长沟通交流的能力,进而提高了实习医生儿科病历书写的质量.

The effect of standardized patient inquiry training on the quality of medical record written by the pediatric interns

Objective To investigate the effect of standardized patient (SP) inquiry training on the quality of medical record written by pediatric interns. Methods One hundred and sixty interns of five-year medical education program in pediatric department were divided into experimental group and control group. After collecting typical cases, the teachers carried out SP inquiry training for 6 times in the experimental group. The teachers simulated the patients' parents and the interns inquired the medical history. At the end of training, the teachers pointed out the merit and defect of the interns. The teachers didn't carry out SP inquiry training in the control group. According to the same standards of grading, the teachers graded and compared medical record scores between the two groups. Results The medical record scores of the experimental group were significantly higher than that of the control group. The scores of format, history of present illness, past history, personal history, family history, diagnosis and differential diagnosis of the experimental group were higher than that of the control group. Conclusions SP inquiry training can help the interns to improve the integrality of inquiry, the clarity of thinking in clinical affairs, the communication skills, and then to improve the quality of medical record written by the pediatric interns.