CAJ | 학술논문

目的：回顾性分析呼吸内科实习医师书写入院病历的问题，探讨提高实习医师书写质量的方法。方法对2013年3—12月382份呼吸内科轮转实习医生书写的入院病历进行回顾性分析，根据2010年颁布的《病历书写基本规范》要求检查。结果检查的入院病历中，各个部分（一般信息、主诉、现病史、体格检查、辅助检查、初步诊断）均存在相应的问题，其中存在问题最多是现病史部分（36．1％），存在问题最少的是辅助检查部分（4．2％）。结论实习医师书写呼吸内科入院病历仍存在问题，因此加强法律法制知识教育，培养专业能力和素质，提高带教老师教学意识，对提高实习医师书写入院病历的质量非常重要。
목적：회고성분석호흡내과실습의사서사입원병력적문제，탐토제고실습의사서사질량적방법。방법대2013년3—12월382빈호흡내과륜전실습의생서사적입원병력진행회고성분석，근거2010년반포적《병역서사기본규범》요구검사。결과검사적입원병력중，각개부분（일반신식、주소、현병사、체격검사、보조검사、초보진단）균존재상응적문제，기중존재문제최다시현병사부분（36．1％），존재문제최소적시보조검사부분（4．2％）。결론실습의사서사호흡내과입원병력잉존재문제，인차가강법율법제지식교육，배양전업능력화소질，제고대교로사교학의식，대제고실습의사서사입원병력적질량비상중요。
Objective To retrospectively analyze problems of admission note written by interns in respiratory medicine department , and explore ways of improving writing quality of the admission note of interns . Methods A total of 382 admission notes from March 2013 to December 2013 were retrospectively analyzed according to the requirement of "fundamental norms of medical record writing"which issued in 2010.Results In these complete admission notes , there were problems in every part , including general information , chief complaint, history of present illness , the physical examination , assistant examination and primary diagnosis .The most problem was history of present illness accounted for 36.1% .The least problem was assistant examination accounted for 4.2%.Conclusions There were many problems of admission note written by interns in respiratory medicine department .We should strengthen legal education , improve interns professional ability and quality , enhance our teachers clinical teaching consciousness , which is very important for improving writing quality of the admission note of interns .