Medical record writing teaching based on tutorial system in standardization training for residents / 中华医学教育探索杂志

ABSTRACT

Objective:To explore the teaching of medical record writing based on tutorial system.Methods:The tutors and residents in standardization training both scored the medical record. The observation indexes included the difference of scoring time between the two editions, the difference of scoring value between tutors and doctors, the distribution of deduction points in medical record writing, and the change trend of medical record score in one year.Results:The scoring value of tutors was significantly lower than that of residents undergoing standardization training ( t=8.919, P<0.05); the deduction of medical records was mainly in the aspects of history of present illness, physical examination, diagnosis and analysis, and treatment plan. After one year of implementation, the score of tutors increased, while that of residents decreased. Conclusion:This method can effectively improve the teaching quality of medical record writing and the ability of residents to discerning problems in medical record writing.