Objective To explore the teaching of medical record writing based on tutorial system. Methods The tutors and residents in standardization training both scored the medical record. The observation indexes included the difference of scoring time between the two editions
the difference of scoring value between tutors and doctors
the distribution of deduction points in medical record writing
and the change trend of medical record score in one year. Results The scoring value of tutors was significantly lower than that of residents undergoing standardization training (t=8.919
P<0.05); the deduction of medical records was mainly in the aspects of history of present illness
physical examination
diagnosis and analysis
and treatment plan. After one year of implementation
the score of tutors increased
while that of residents decreased. Conclusion This method can effectively improve the teaching quality of medical record writing and the ability of residents to discerning problems in medical record writing.