Common problems and countermeasures of clinical medical interns' writing medical records in the department of hematology
10.3760/cma.j.issn.2095-1485.2018.07.020
- VernacularTitle:临床医学专业实习生书写血液科病历的常见问题与对策
- Author:
Hongju DOU
1
;
Hong ZHU
;
Yan ZHUANG
;
Liu YANG
;
Qi ZHU
;
Yuanmei CHEN
Author Information
1. 200011,上海交通大学医学院附属第九人民医院血液内科
- Keywords:
Interns of clinical medicine;
Hematology department;
Quality of medical record
- From:
Chinese Journal of Medical Education Research
2018;17(7):737-741
- CountryChina
- Language:Chinese
-
Abstract:
In order to improve the quality of medical records written by interns of clinical medicine in hematology department,we evaluated and analyzed 100 medical records written by the interns.The main reasons that affect the quality of medical record written by interns are the writing defects that are history of present illness,past history,personal history,the record of the clinical operation,blood transfusion and chemotherapy.There are other reasons for affecting the quality of medical records,such as students in clinical practice not paying attention to the writing of medical records,the relative lag of teaching management,the particularity of the diseases in the department of hematology and the weak legal consciousness.Therefore,we should strengthen the teaching management,improve the comprehensive quality of the clinical teaching teachers,carry out the pre job training of the medical records for the interns,train the interns' inquiries and the ability to communicate with the doctors and patients,and make use of the typical medical records of the Department of Hematology to combine the discussion and other ways,so as to strengthen the interns' clinical disease writing skills and legal consciousness as well as the quality of their writing medical records.
