Research on effects of EMR on ability training of intern doctors' history-collecting and medical-records writing / 中华医学教育探索杂志

ABSTRACT

Objective To know the effects of electronic medical records(EMR) on the training quality of intern doctors' history-collecting and medical-records writing.Methods 195 students from Nantong University,Suzhou University and Xuzhou medical college were chosen as the subjects.For better effects,we divided the 195 students into two groups,81 students of Grade 2007 as the control group(hand-written medical record group) and 114 students of Grade 2008 as study group (electronic medical record group).The control group was arranged to complete EMR by transcribing the teacher's handwriting records into formal medical records after teachers' guidance and modification while the study group was arranged to write and directly modify the records on computer under the guidance of teachers and submit them for formal records.After the teaching,the medical record writing quality of two groups of interns was conducted centralized assessment to analyze the advantages and disadvantages of electronic medical records on the training of interns' collection and writing ability.SPSS 18.0 was used for statistical analysis,with count data using the number(percentage) and measurement data using mean +/-standard deviation.Measurement data of two groups of medical record writing scores were compared with t test,test level for α=0.05.Results The result of handwritten group was significantly better than EMR group(t=6.33,P＜0.001),which indicated training effectiveness of intern doctors' ability of writing medical record had digressive tendency on EMR group.Conclusion Negative effects of EMR are shown in intern doctors' history-collecting and medical-records writing.Cultivation quality of intern doctors' history-collecting and medical-records writing should be ensured by the combination of EMR and handwriting-medical training,the combination of daily inspection and key examination of medical record writing quality and establishment of feedback-rectification mechanism.