研究型病历在血管外科住院医师规范化培训中的作用.doc

研究型病历在血管外科住院医师规范化 培训中的作用 袁良喜 朱广浪 陆清声 赵志青 包俊敏 周建 景在 ￥ 第二军医大学附属长海医院血管外科 ： 目的探讨研究型病历在血管外科住院I矢师规范化培训中的作用。方法将2015 年10月2016年9月在长海医院血管外科学习的84名住院医师随机分为研究型 病历组41名和传统型病历组43名，研究型病历组医师完成一份研究型病历，传 统型病历组医师完成一份普通电子病历，比较两组医师在临床教学质量、临床科 学研究方而的差异。结果临床教学质量方面:研究型病历组住院医师的病历质量 评分有改进75. 6%,高于传统型病历组46.5%,差界有统计学意义（P二0.006）; 病历资料的完整性与准确性有改进85. 4%,高于传统型病历组55. 8%,差异有统 计学意义（P=0. 003）;诊疗计划的熟知情况方面有改进80. 5%,高于传统型病历 组53. 5%,差异有统计学意义（P二0.016）。临床科学研究方面:研究型病历组在 科研数据的完整性方而有改进85. 4%,高于传统型病历组58. 1%,差异有统计学 意义（P二0.006）;疾病诊断亚分类的准确合理性有改进82. 9%,高于传统型病历 组55. 8%,差异有统计学意义（P二0.006）;住院医师科研思路的影响有改进 80.5%,高于传统型病历组51.2%,差异有统计学意义（P二0.006）。结论研究 型病历在血管外科住院医师规范化培训屮发挥积极作用，提高了临床教学质量 和临床科学研究水平。 关键词： 研究型病历;住院医师规范化培训; ：周建，xueguankyz@163. com 基金：国家自然科学基金青年项Fl （项目编号 Application of research medical recordsinstandardizedtraining of vascular house surgeons YUANLiangxi ZHUGuonglang LUQingsheng Department of Vascular Surgery, the Changhai Hospital of Shanghai; Abstract： Objective To explore the applicationeffects of research medical records in the stemdardized training of residents inthe vascular surgery dcpartment. Methods 84 resident doctors studying in our department bet ween Oct 2015 and Sep 2016 were collected andrandomly divided into two groups: 41 cases ofresearch ( medical record) groupand 43 cases of traditional ( medical record) group. Residentsin the research group were asked to finish research medical records, whi1e residents in the t rad itio nal group were asked to finish comm on clcc trical medical records. By means of questioningin teaching ward rounds or departmental rotation examination, all house surgeons receivedevaluationabouttheir quality of clinical teaching and research. ResuIts In aspect of clinical teaching quality, the improvement percentage of quality scoring ofmedical records in the research group ( 75. 6%) wassignificantlyhighcr than that in the traditional group ( 46. 5%) ( P = 0. 006) , so was the improvement percentage of integrity and accuracy of medical records, and the improvement perc