摘要
目的探讨SOAP[主观资料(subjective data,S)、客观资料(objective data,O)、评估(assessment,A),诊疗计划(plan,P)]教学方法联合迷你临床演练评估(mini clincal evaluation exercise,Mini-CEX)在口腔住院医师规范化培训(以下简称住培)门诊病历书写教学中的应用效果。方法选择2019—2021年在浙江大学医学院附属杭州市第一人民医院接受口腔住院医师规范化培训的52名学员为研究对象,在口腔综合科轮转期间采用SOAP教学方法进行门诊病历书写培训,入科前和出科时分别对其采用Mini-CEX考核和门诊病历书写笔试考核,采用SPSS 22.0软件对考核成绩进行统计学处理和比较。结果Mini-CEX考核包括病史采集、体格检查、辅助检查、临床诊断4项指标,口腔住培学员出科时考核评分比入科前考核评分均有明显提高,其差异均具有统计学意义(均P<0.05)。门诊病历书写笔试的各项内容,口腔住培学员出科时评分比入科前评分均有明显提高,其差异均具有统计学意义(均P<0.05)。结论SOAP教学方法联合Mini-CEX可以有效提高口腔住培学员门诊病历书写质量,是一种高效的培训方式,值得推广应用。
Objective To explore the application of SOAP(subjective data-objective data-assessment-plan)teaching method combined with Mini-CEX in the teaching of outpatient medical record writing in standardized training of stomatological residents.Methods 52 stomatological residents of Hangzhou First People s Hospital Affiliated to Zhejiang University School of Medicine from 2019 to 2021 were selected as the research objects.SOAP recording method was used for training during the rotation of department of general stomatology.The Mini-CEX assessment and medical record writing examination were used before and after the rotation period.SPSS 22.0 was used to analyze the scores.Results The Mini-CEX scores of medical history collection,physical examination,auxiliary examination and clinical diagnosis after teaching were significantly improved,compared with those before rotation(all P<0.05).There were significant differences in the examination scores of medical records writing after teaching,compared with those of the former ones(all P<0.05).Conclusions SOAP teaching method combined with Mini-CEX can effectively improve the quality of outpatient medical record writing in standardized training of stomatological residents.
作者
黄婕
张黄
范旭升
王永武
苗瑞婧
涂敏松
HUANG Jie;ZHANG Huang;FAN Xusheng;WANG Yongwu;MIAO Ruijing;TU Minsong(Department of Endodontics,Hangzhou First People s Hospital Affiliated to Zhejiang University School of Medicine,Hangzhou 310006,China;Department of Prosthodontics,Hangzhou First People s Hospital Affiliated to Zhejiang University School of Medicine,Hangzhou 310006,China)
出处
《浙江医学教育》
2023年第4期237-241,共5页
Zhejiang Medical Education
关键词
口腔住院医师
门诊病历书写
SOAP教学方法
迷你临床演练评估
Stomatological resident
Outpatient medical records writing
SOAP teaching method
Mini clinical evaluation exercise
