CAJ | 학술논문

病历书写规范化培训是新毕业医师临床见习期间学习的常规形式之一。它能有效的促进新毕业医师对书写病历能力的认识。如何在临床见习这一关键阶段有效地提高新毕业医师规范病历书写能力至关重要。作者对传统的会议室岗前培训方式进行了改革性尝试，采用了以病案为基础的教学模式，用具体病案来引导新毕业医师进行终末病案质量检查、讨论，更有助于培养病历书写能力，从而提高病案书写质量，收到了良好的教学效果。
병역서사규범화배훈시신필업의사림상견습기간학습적상규형식지일。타능유효적촉진신필업의사대서사병력능력적인식。여하재림상견습저일관건계단유효지제고신필업의사규범병역서사능력지관중요。작자대전통적회의실강전배훈방식진행료개혁성상시，채용료이병안위기출적교학모식，용구체병안래인도신필업의사진행종말병안질량검사、토론，경유조우배양병역서사능력，종이제고병안서사질량，수도료량호적교학효과。
Standard training of medical record writing is the one of regular form for medical undergraduates and can improve the understanding of writing medical record. How to improve ability of writing medical record is very important in clinical practice. We try to adopt case-based study(CBS) teaching mode instead of traditional pre job training and use concrete medical cases to teach newly graduated doctors how to check and discuss the quality of medical records, which is helpful to cultivate standards of writing medical records to improve quality of medical records and received good teaching results.