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目的研究以病案为基础教学法(CBS)在病历书写规范化培训中的应用效果。方法以某院2016年100名住院医师规范化培训学员为研究对象,随机分为试验组(n=50)和对照组(n=50),分别采用CBS模式和传统模式进行培训,比较2组学员培训前后的理论考试成绩和病历书写质量评分,并发送培训效果反馈问卷调查表。计数资料采用χ2检验比较两组间差异,计量资料采用t检验进行统计分析,以P<0.05为差异有统计学意义。结果在住院医师病历书写规范化培训中,无论是理论考试成绩还是病历书写的规范性和完整性评分,接受CBS培训模式组(97.06±2.22,96.14±2.91,97.86±1.59)均显著高于传统模式组(93.02±4.07,91.14±4.63,95.44±2.64),差异有统计学意义(P<0.05)。结论 CBS培训模式能够通过提升学员的课堂注意力、学习兴趣和记忆效果,从而提高住院医师的理论知识水平和病历书写能力及质量。
Objective To study the application effect of case-based teaching method (CBS) in the standardized training of medical record writing. Methods A total of 100 residency regularized trainees in a hospital from 2016 to 2016 were randomly divided into experimental group (n = 50) and control group (n = 50), and were trained by CBS model and traditional model respectively. Two groups of students Before and after training the theoretical test scores and medical record quality score, and send training feedback questionnaire. Count data using χ2 test to compare the differences between the two groups, measurement data using t test for statistical analysis, P <0.05 was considered statistically significant. Results In the normative training of resident medical records writing, both the theoretical test scores and the normative and integral scores of medical record writing, the CBS training model group (97.06 ± 2.22, 96.14 ± 2.91, 97.86 ± 1.59) were significantly higher than the traditional model Group (93.02 ± 4.07,91.14 ± 4.63,95.44 ± 2.64), the difference was statistically significant (P <0.05). Conclusion The CBS training model can improve the theoretical knowledge and medical record writing ability and quality of residency by improving students’ classroom attention, learning interest and memory effect.