追踪方法学在实习医师病历书写培训中的应用

目的：探讨追踪方法学对实习医师病历书写培训的效果。方法将2012年7月接受病历书写培训的实习医师50名设为对照组，采用传统培训方法，即在实习医师的岗前培训期间开展病历书写培训。将2013年7月接受病历书写培训的实习医师58名设为调查组，采用追踪方法学培训，即在实习医师的岗前培训前开展病历书写问卷调查，然后根据调查情况有针对性地开展病历书写培训。培训结束后，再次采用基于卫生部《病历书写基本规范》的问卷对2组实习医师进行调查。数据采用Excel软件录入整理，应用SPSS 21.0统计软件进行分析，计数资料行χ2检验。结果培训后病历书写相关知识调查考核中，调查组对病历书写的基本要求、基本原则、病史采集、病历书写记录的时限、实习医师需掌握病历书写的内容、需要患者签署的医疗文书等问题回答的正确率与对照组比较，差异有统计学意义（P＜0.05）。结论追踪方法学在实习医师病历书写培训中效果明显，值得在临床教学中推广应用。

Application of tracer methodology in the training of intern medical record writing

Objective To discuss the effectiveness of tracer methodology in the training of intern medical record writing. Methods Fifty interns who received medical record writing training in July 2012 were set as control group and were trained by traditional methods. Meanwhile, 58 interns who received medical record writing training in July 2013 were set as investigation group and were trained by tracer methodology. Pre-training questionnaire survey was conducted for interns in investigation group and targeted training was provided. After the training, interns in two groups were surveyed by questionnaire of basic norms of medical record writing. Excel software was used to do data entry and SPSS 21.0 statistical software was used to statistical analysis. P＆lt;0.05 signifies statistical differences. Results Final record writing exam after the training demonstrated that there were significant differ-ences in basic requirement of record writing, basic principle of record writing, history taking, record time limit, contents of record writing and correct rate of patients＆#39; answer to the document between in-vestigation group and control group with statistical differences（P＆lt;0.05）. Conclusion Tracer method-ology has obvious effects in intern medical record writing training and is worth popularization and ap-plication in clinical teaching.