重视学生病历书写训练提高儿科病历书写质量

书写系统而完整的病历是临床医师必须掌握的一项基本技能.本文从主诉、现病史、个人史、体格检查、诊断、诊断依据、鉴别诊断和治疗计划等方面,对见习医学生在儿科病历书写时存在的主要问题进行了分析,并提出了提高见习医学生儿科病历书写质量的方法,即强调病历书写的重要性、将病历书写成绩作为见习成绩的组成部分、系统讲授儿科病历的特点、采用床边教学以提高见习医学生问诊和体格检查能力、开展病历讲评等.

Emphasis on the training of novitiates' medical records writing to improve the quality of pediatric medical records

To write systematic and integrative medical records is a basic skill that clinical doctors must master skillfully.In this article the main problems existed in the pediatric medical records written by novitiates were analyzed in chief complaints,history of present illness,personal history,physical examination,diagnosis,differential diagnosis and treatment plan.Some methods to improve the quality of pediatric medical records writing were offered,such as emphasis on the importance of medical records writing,making the score of medical records writing as part of pediatric scores of novitiates,giving systematic lectures on the characteristics of pediatric medical records,using bedside teaching to improve the novitiates' ability of inquiry and phyrsical examination,evaluating pediatric medical records and so on.