住院病历书写指导在住院医师规范化培训中的效果及应用研究

Effect and Application of Inpatient Medical Record Writing Guidance in Standardized Training of Resident Physicians

摘要: 目的：通过对住院医师参加规范化培训进行调查分析，探索住院病历书写指导在住院医师规范化培训中的应用价值。方法：将2019级到2022级的规范化培训的住院医师纳入研究，根据是否开展住院病历书写指导，将患者划分为四组：A组(2022级住培学员，40名)进行3年住院病历指导教学并评量、B组(2021级住培学员，31名)进行2年住院病历指导教学并评量、C组(2020级住培学员，30名)进行1年住院病历指导教学并评量、D组(2019级住培学员，34名)已结业，未进行规范的住院病历指导教学。根据采用住院病历书写指导对住院医师规范化培训进行优化，对比改进前后住院医师病历质量评分、问卷调查数据进行分析。结果：通过改进对临床医师进行规范化实践能力培训的措施后，A组住院医师在病历质量评分、临床医师培训满意度，均明显高于其他组(P < 0.05)。结论：对于规范化培训中的住院医师来说，住院病历书写对于其能力的提升具有重要意义。医院要根据有需要的住院医师进行合理培训，采用住院病历书写指导，优化培训方法，提高规范化培训的质量。

Abstract: Objective: Through the investigation and analysis of resident physicians’ participation in standardized training, the application value of inpatient medical record writing guidance in standardized training was explored. Method: The study included standardized training resident physicians from the 2019 to 2022 cohorts. Patients were divided into four groups based on whether they received guidance in writing inpatient medical records: Group A (2022 cohort residents, 40), who received three years of guidance in writing inpatient medical records and were evaluated; Group B (2021 cohort residents, 31), who received two years of guidance in writing inpatient medical records and were evaluated; Group C (2020 cohort residents, 30), who received one year of guidance in writing inpatient medical records and were evaluated; Group D (2019 cohort residents, 34), who had completed their training but did not receive standardized guidance in writing inpatient medical records. The study aimed to optimize the standardized training of resident physicians by using guidance in writing inpatient medical records, and to compare the quality scores of resident physicians; medical records before and after the improvement, as well as analyzing the data from questionnaire surveys. Results: After improving the standardized practice training measures for clinicians, the medical records quality score and clinical physician training satisfaction of group A residents were significantly higher than those of other groups (P < 0.05). Conclusion: For resident physicians in standardized training, the writing of inpatient medical records is of great significance to their ability improvement. Hospitals should carry out reasonable training according to the resident physicians in need, adopt the guidance of inpatient medical records writing, optimize the training methods, and improve the quality of standardized training.