重庆医学2011，Vol.40Issue(16)：1614-1615,1618,3.DOI:10.3969/j.issn.1671-8348.2011.16.022
从病历质量看住院医生培养中的问题
Problems in resident physicians training by analyzing quality of medical records and their solutions
梅晶 1王琳1
作者信息
- 1. 第三军医大学大坪医院野战外科研究所神经内科,重庆,400042
- 折叠
摘要
Abstract
Objective To discuss problems of resident physicians training and their solutions. Methods Collect medical records of discharged patients from 1 January 2010 to 30 June 2010 from medical history information database of Daping hospital according to key words such as insomnia, chronic insomnia, anxiety-depression and somatoform disorders, and self-created form was adopted to analyze quality of medical records. Results Sleep disorder was recorded as the chief complaint by mistake in 31.5％ medical records. History of present illness in 42.4％- 70.1％ medical records did not contain detailed descriptions of sleeping quality. The clinical history characteristics in 84.3 ％ medical records were copies of their history of present illness with superficial discussions for preliminary diagnosis. 46.3 ％ medical records had inaccurate terms of final diagnosis. Conclusion Some resident physicians lack basic knowledge and theories related to insomnia,and their learning of fundamental theories and technology should be enhanced.关键词
病历质量/失眠/住院医师/教育Key words
quality of medical record / insomnia / resident physician / education引用本文复制引用
梅晶,王琳..从病历质量看住院医生培养中的问题[J].重庆医学,2011,40(16):1614-1615,1618,3.
