摘要
目的研究"以考促学"联合病案导入式(CBS)教学法在病历书写规范化培训中的应用效果。方法以某院2017级和2018级共446名住院医师规范化培训学员为研究对象,2017级214名学员为对照组,2018级232名学员为实验组,分别采用传统模式和"以考促学"联合CBS教学模式进行培训,培训后发放试卷进行考核,比较两组学员的培训效果。结果对照组学员平均得分为76.03±11.64,实验组学员平均得分为86.14±8.05,实验组学员得分情况高于对照组学员。实验组学员对入院情况、其他诊断、手术及操作名称、离院方式、主诉、既往史、日常病程记录、上级医师查房记录、现病史、手术记录书写规范、书写时限题目的正确率高于对照组学员,差异存在统计学意义(P<0.05)。结论"以考促学"联合CBS教学模式是一种较好的且具有可行性、可推广性的培训模式,能短时高效地提高住院医师的病历书写能力。
Objective To study the application effect of"Promoting learning by examination"combined with CBS teaching mode in the standardized training of medical record.Methods A total of 446 residents in the class of 2017 and 2018 were selected as the subjects.The 214 residents of class 2017 were selected as the control group,and the 232 residents of class 2018 were selected as the test group.The"Promoting learning by examination"combined with CBS teaching mode was used for the test group while the traditional model was used for the control group.The examinations were taken to analysis the training effect of the two groups.Results The average score of the residents in the control group and the test group was 76.03±11.64 and 86.14±8.05 respectively.The score of the residents in the test group was higher than that of the control group.The correct answer rates of the test group residents of the admission condition,other diagnosis,name of operation and operation,method of leaving hospital,chief complaint,past history,daily course record,ward round record of superior physician,medical history of present illness,writing standard of surgical record and the time limit of medical recordis were higher than that of the control group residents,there are statistically significant differences between the two groups(P<0.05).Conclusion The"Promoting learning by examination"combined with CBS teaching mode is a good and feasible training model,which can effectively improve the writing ability of medical records of residents in a short time.
作者
李梦娜
何玉芸
林慕蕾
赵淑媛
Li Mengna;He Yuyun;Lin Mulei;Zhao Shuyuan(Medical Record Department,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangzhou 510000,Guangdong Province,China)
出处
《中国病案》
2020年第2期79-81,共3页
Chinese Medical Record
关键词
CBS模式
病历书写
住院医师
规范化培训
CBS model
Medical record writing
Residents
Standardized training
