Application of structured electronic medical records for pulmonary nodules in standardized training of resident physicians
- VernacularTitle:肺结节结构化电子病历在住院医师规范化培训中的应用
- Author:
Si’en SHI
1
;
Xiuyi YU
1
;
Sheng FAN
1
;
Guojun GENG
1
;
Jie JIANG
1
Author Information
1. Department of Thoracic Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, Fujian, P. R. China
- Publication Type:Journal Article
- Keywords:
Standardized training of resident physicians;
pulmonary nodules;
structured electronic medical records;
clinical teaching;
case writing
- From:
Chinese Journal of Clinical Thoracic and Cardiovascular Surgery
2022;29(06):703-710
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the value of structured electronic medical records for pulmonary nodules in increasing the ability of outpatient service and hospital management by resident physicians. Methods We included 40 trainees [94 males and 26 females aged 22-31 (26.45±2.81) years] who were trained in the standardized training base for surgical residents in our hospital from January 2018 to January 2021. The trainees were randomly divided into two groups including a structured group using the structured electronic medical record for pulmonary nodule and an unstructured group using unstructured electronic medical record designed by our department. The time of completing hospitalization records and first-time course records, the quality of course records, the accuracy of issuing admission orders, the quality of teaching rounds, and patient’s satisfaction between the two groups were analyzed and compared. Results (1) The average time in the structured group to complete inpatient medical records was significantly shorter than that of the unstructured group (53.61±8.12 min vs. 84.25±16.09 min, P<0.010); the average time in the structured group to complete the first-time course record was shorter than that of the unstructured group (13.20±5.43 min vs. 27.51±8.62 min, P<0.010), and there was a significant statistical difference between the two groups. (2) The overall teaching round quality score of the students in the structured group was significantly higher than that in the unstructured group (84.21±15.61 vs. 70.91±12.28, P<0.010). (3) The score of the medical record writing quality of the structured group was significantly higher than that of the unstructured group (80.25±9.22 vs. 74.22±5.40, P<0.010). Conclusion The structured electronic medical record specific for pulmonary nodules can effectively improve the training efficiency in the standardized training of surgical residents, improve the clinical ability to deal with pulmonary nodules, improve the integrity and accuracy of key clinical data collected by students, and improve doctor-patient relationship.
