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目的分析中医规范化培训住院医师(简称规培医师)首次病程书写质量缺陷问题,并探讨应对策略。方法分析2014年第四季度轮转首都医科大学附属北京中医医院脾胃病科规培医师书写的197份首次病程质量缺陷。结果规培医师首次病程的诊疗计划部分书写缺陷最多;培训时间较长者病历书写质量高;女医师书写病历质量较男医师高;临床型硕士学历者书写病历缺陷最少。带教老师对于专科疾病应深入细致讲解,以提高规培医师对疾病的整体把控;可制定严格的考核体系,择优毕业;对于科研型医师应适当延长培养时间以提高培训质量。结论规培医师首次病程的书写存在部分缺陷,需要带教老师采取多种对策,以提高首次病程的书写质量。
Objective To analyze the quality defects of the first course of Chinese medicine standardized training residents (referred to as training physicians), and to explore coping strategies. Methods A total of 197 quality defects of the first course of disease written by physicians and physicians of the spleen and stomach diseases department, Beijing TCM Hospital, Capital Medical University in the fourth quarter of 2014 were analyzed. Results The training program for part-time physicians for the first time had the most writing defects. The quality of the medical records was higher than that for the older ones. The quality of medical records for female physicians was higher than that for male physicians. The clinical master’s degree recorded the least number of medical records. Teaching teachers for specialist diseases should be explained in detail, in order to improve the regulatory training physicians on the overall control of the disease; can develop a rigorous evaluation system, merit graduates; for research physicians should be appropriate to extend the training time to improve the quality of training. Conclusions There is some flaws in the writing of the first course of the program training physicians, teachers need to take a variety of measures to improve the writing quality of the first course of the disease.