心内科实习医生书写入院病历的缺陷分析和策略探讨

目的 分析心内科实习医生书写入院病历的缺陷,探讨提高实习医生书写心内科入院病历质量的策略.方法 对2013年5月～ 2013年12月我科69份实习医生书写的入院病历进行回顾性分析,检查依据2010年卫生部颁布的《病历书写基本规范》要求.结果 有缺陷的病历占82.6％（57/69）,其中一般项目填写不准确的占21.7％（15/69）,主诉存在问题的占26.1％（18/69）,现病史存在问题的占62.3％（43/69）,既往史、个人史、月经婚育史、家族史有缺项或描述不准确的占20.3％（14/69）,体格检查存在问题的占46.4％（32/69）,初步诊断存在问题的占56.5％（39/69）.结论 大部分实习医师书写入院病例存在多项缺陷,提高实习医生法律意识,加强三基训练和岗前培训,充分发挥临床带教老师“传、帮、带”的作用,对提高实习医生书写心内科入院病历的水平至关重要.

Defect Analysis and Strategies of Cardiology Medical Interns Writing Admission Note

Objective To analyze the written defects of admission note of cardiology medical interns, and ways of improving the admission note of cardiology medical interns writing quality. Methods A total of 69 admission notes from May 2013 to December 2013 were retrospectively analyzed according to the requirement of ＂basic norms of medical writing＂ which the ministry of health issued in 2010. Results There are defects accounted for 82.6% （57/69）, generally item fill inaccurate accounted for 21.7% （15/69）, complaint problems accounted for 26.1% （18/69）, history of present illness problems accounted for 62.3% （43/69）, the defects of past history, personal history, menstrual obstetrical history, family history accounted for 20.3% （14/69）, the physical examination problems accounted for 46.4% （32/69）, problems of initial diagnosis accounted for 56.5% （39/69）. Conclusion Most of the interns writing exist defects. We should improve interns legal awareness, strengthen three basic training and pre-service training, give full play to the clinical teaching teachers ＂Mentoring＂ to improve writing level of medical record of Cardiology medical interns.