电子病历对临床教学的影响与改进
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摘要
电子病历凭借其大容量、易保存、易管理的优势已成为现代医学发展的趋势,已逐渐推广应用并替代传统的手写病历,减少临床医师的文书工作,提高了工作效率,在临床和科研工作中发挥了重要的作用,但在临床教学中仍存在诸多问题。过分依赖电子病历模板,套用模板复制现成的内容,忽略了详实地记录病史及查体,甚至存在错误,严重影响了病历的质量,同时住院医师在书写病历时丧失自己思考的过程和学习的意义。通过法律法规学习提高对病历书写重要性的思想认识、加强医德医风教育、提高住院医师的自我认同感,提高临床教师对病历的重视程度和指导能力及建立考核与奖惩制度等方法,切实解决目前存在的问题,充分发挥电子病历系统在教学工作中的助力作用。
Electronic medical records have become the trend of modern medicine for its advantages of large capacity, convenience of preservation and management. It has replaced the traditional hand-written medical records,reduced the paperwork of clinicians, improved work efficiency, and played an important role in clinical and scientific research. But there are still many problems in clinical teaching. Relying too much on medical record templates, copying the ready-made content from templates, ignoring the details of the history and examination,which severely affected the quality of the medical records. The residents lost their own thinking and learning process in writing. We should enhance their awareness of the importance medical records writing from learning the laws,strengthen the medical ethics education and the self-identification of the residents, improve guiding ability of clinical teachers and establish the system of assessment in order to solve the existing problems. Electronic medical record system should play a full role in teaching work.
Electronic medical records have become the trend of modern medicine for its advantages of large capacity, convenience of preservation and management. It has replaced the traditional hand-written medical records,reduced the paperwork of clinicians, improved work efficiency, and played an important role in clinical and scientific research. But there are still many problems in clinical teaching. Relying too much on medical record templates, copying the ready-made content from templates, ignoring the details of the history and examination,which severely affected the quality of the medical records. The residents lost their own thinking and learning process in writing. We should enhance their awareness of the importance medical records writing from learning the laws,strengthen the medical ethics education and the self-identification of the residents, improve guiding ability of clinical teachers and establish the system of assessment in order to solve the existing problems. Electronic medical record system should play a full role in teaching work.
引文
[1]马如慧,刘延洲.电子病历在教学和科研中的应用[J].医疗卫生装备,2011.32(4):97-98.
[2]周庆.电子病历对实习生病史采集与病历书写能力影响的研究[J].中华医学教育探索杂志,2014.13(12):1214-1218.
[3]巨春蓉,陈荣昌.电子病历对医学生实习行为和实习效果的影响[J].中华医学教育杂志,2013.33(1):100-101,147.
[4]朱宏勋.临床教学中应用电子病历模板的问题及对策[J].中国病案,2014.15(2):65-66.
[5]夏经刚,胡少东,许骥,等.规范化教学中电子病历书写培训[J].中国病案,2015.16(3):62-63.
[6]倪受文,花良凤.浅议临床医学教育管理受到相关医疗法律法规的影响[J].高教学刊,2016(12):169-170.
[7]李娟,江敏,陈鸿雁,等.临床医学师资教学能力培养探索与实践[J].中国继续医学教育,2017.9(8):31-33.
[8]孙荣,唐新业,杨阳.高等医学院校实行讲课比赛对临床青年教师教学能力的影响[J].现代医药卫生,2015(18):2873-2874.
[2]周庆.电子病历对实习生病史采集与病历书写能力影响的研究[J].中华医学教育探索杂志,2014.13(12):1214-1218.
[3]巨春蓉,陈荣昌.电子病历对医学生实习行为和实习效果的影响[J].中华医学教育杂志,2013.33(1):100-101,147.
[4]朱宏勋.临床教学中应用电子病历模板的问题及对策[J].中国病案,2014.15(2):65-66.
[5]夏经刚,胡少东,许骥,等.规范化教学中电子病历书写培训[J].中国病案,2015.16(3):62-63.
[6]倪受文,花良凤.浅议临床医学教育管理受到相关医疗法律法规的影响[J].高教学刊,2016(12):169-170.
[7]李娟,江敏,陈鸿雁,等.临床医学师资教学能力培养探索与实践[J].中国继续医学教育,2017.9(8):31-33.
[8]孙荣,唐新业,杨阳.高等医学院校实行讲课比赛对临床青年教师教学能力的影响[J].现代医药卫生,2015(18):2873-2874.