中华医学教育杂志
中華醫學教育雜誌
중화의학교육잡지
CHINESE JOURNAL OF MEDICAL EDUCATION
2010年
4期
607-609
,共3页
余慕雪%蒋小云%岳智慧%李晓瑜%李易娟%马华梅%古玉芬
餘慕雪%蔣小雲%嶽智慧%李曉瑜%李易娟%馬華梅%古玉芬
여모설%장소운%악지혜%리효유%리역연%마화매%고옥분
标准化病人%同诊培训%儿科学%实习医生%病历
標準化病人%同診培訓%兒科學%實習醫生%病歷
표준화병인%동진배훈%인과학%실습의생%병력
Standardized patient%Inquiry training%Pediatrics%Intern%Medical record
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.
目的 探討標準化病人(standardized patient,SP)問診培訓對兒科實習醫生病歷書寫質量的影響.方法 將160名五年製臨床醫學專業實習醫生分為實驗組和對照組,教師採集典型病案,對實驗組實習醫生進行6次教師模擬SP的問診培訓,即採取教師模擬患兒傢長、實習醫生嚮教師詢問病史的方法進行問診培訓.培訓後教師進行總結,指齣實習醫生在問診方麵的優點和缺點.對照組實習醫生不進行SP問診培訓.最後對兩組實習醫生書寫的病歷進行統一評分及比較.結果 實驗組實習醫生病歷書寫總成績高于對照組;實驗組實習醫生書寫的病歷在格式、現病史、既往史、箇人史、傢族史、診斷和鑒彆診斷等方麵的單項評分也高于對照組.結論 SP問診培訓能夠提高兒科實習醫生問診的完整性,使實習醫生的思路明確,培養瞭實習醫生與患兒傢長溝通交流的能力,進而提高瞭實習醫生兒科病歷書寫的質量.
목적 탐토표준화병인(standardized patient,SP)문진배훈대인과실습의생병역서사질량적영향.방법 장160명오년제림상의학전업실습의생분위실험조화대조조,교사채집전형병안,대실험조실습의생진행6차교사모의SP적문진배훈,즉채취교사모의환인가장、실습의생향교사순문병사적방법진행문진배훈.배훈후교사진행총결,지출실습의생재문진방면적우점화결점.대조조실습의생불진행SP문진배훈.최후대량조실습의생서사적병력진행통일평분급비교.결과 실험조실습의생병역서사총성적고우대조조;실험조실습의생서사적병력재격식、현병사、기왕사、개인사、가족사、진단화감별진단등방면적단항평분야고우대조조.결론 SP문진배훈능구제고인과실습의생문진적완정성,사실습의생적사로명학,배양료실습의생여환인가장구통교류적능력,진이제고료실습의생인과병역서사적질량.
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.
