Common problems analysis and improvements of medical records writing in the standardized residency training of ophthalmology
10.3760/cma.j.cn116021-20201029-01075
- VernacularTitle:眼科住院医师规范化培训中病历书写的常见问题及改进措施
- Author:
Yu SU
1
;
Changzheng CHEN
;
Xixi YAN
;
Lu LI
;
Tao HE
Author Information
1. 武汉大学人民医院眼科中心，武汉 430060
- Keywords:
Ophthalmology;
Standardized residency training;
Medical records writing
- From:
Chinese Journal of Medical Education Research
2022;21(11):1530-1533
- CountryChina
- Language:Chinese
-
Abstract:
Objectives:To investigate common problems analysis and improvements of medical records writing in the standardized residency training of ophthalmology.Methods:A total of 100 defective medical records of Renmin Hospital of Wuhan University from September 2019 to January 2020 were collected and analyzed for the problems and the reasons, as well as the improvements.Results:A total of 286 defects were found in these 100 medical records. Of which, content-related defects were detected in 89 medical records (31.12%), while quality-related problems were found in 151 records (52.80%). In addition, other defects were found in 46 records (16.08%). Major reasons included personal attitude, insufficient ophthalmic knowledge, heavy workload, lack of standardized guidance and insufficient communicational skills.Conclusion:By analyzing the major reasons of medical records writing, the following approaches, including standardized pre-job training, learning of medical dispute cases and online training, communicational skills training, in-time feedback and evaluation improvement, would be help to reduce the defects in the medical records written by ophthalmic residents.
