继续医学教育2025，Vol.39Issue(11)：92-96,101,6.DOI:10.3969/j.issn.1004-6763.2025.11.020
复合式培训模式在实习生病历首页书写教学中的应用研究
Research on the Application of Compound Training mode in the Teaching of Writing the First Page of Medi-cal Records for Interns
摘要
Abstract
Objective To explore the application effect of the lecture on the writing norms of the first page of acute stroke medical records and Peking University Medical In-formation System in the teaching of interns Methods 150 clinical medicine interns in our hospital from July 2021 to July 2024 were randomly divided into the observation group(acute stroke medical record home page writing standard lecture+Peking University medical information system training),the control group 1(routine training),control group 2(routine training+Peking University med-ical information system training),with 50 cases in each group.The learning initiative,post competency,medical re-cord writing error rate and training satisfaction were com-pared among the groups.Results Comparison of the total incidence of writing errors/irregularities on the first page of medical records among the three groups,the observation group<the control group 1,2(P<0.05).After training,the active learning scale(ALS)and post competency scores of the three groups were compared,the observation group>the control group 2>the control group 1(P<0.05).The training satisfaction of the observation group was higher than that of the control group 1 and 2(P<0.05).Conclusion The lecture on the writing norms of the first page of acute stroke medical records combined with the Peking University Medical Information System can ef-fectively improve the writing quality of acute stroke medi-cal records and the training satisfaction of interns.关键词
病历首页/书写规范/讲座/急性脑卒中/规范化培训/北大医信系统Key words
medical record homepage/writing norms/lec-ture/acute stroke/standardized training/Peking University Medical Information System分类
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刘海英,刘一佳,吾尔娜,裴斐菲..复合式培训模式在实习生病历首页书写教学中的应用研究[J].继续医学教育,2025,39(11):92-96,101,6.基金项目
新疆神经系统疾病研究重点实验室开放课题(XJDX1711-2122) （XJDX1711-2122）
