In order to improve the quality of medical records written by interns of clinical medicine in hematology department
we evaluated and analyzed 100 medical records written by the interns. The main reasons that affect the quality of medical record written by interns are the writing defects that are history of present illness
past history
personal history
the record of the clinical operation
blood transfusion and chemotherapy. There are other reasons for affecting the quality of medical records
such as students in clin-ical practice not paying attention to the writing of medical records
the relative lag of teaching management
the particularity of the diseases in the department of hematology and the weak legal consciousness. Therefore
we should strengthen the teaching management
improve the comprehensive quality of the clinical teach-ing teachers
carry out the pre job training of the medical records for the interns
train the interns' inquiries and the ability to communicate with the doctors and patients
and make use of the typical medical records of the Department of Hematology to combine the discussion and other ways
so as to strengthen the interns' clinical disease writing skills and legal consciousness as well as the quality of their writing medical records.
关键词
临床医学专业实习生 血液科 病历书写质量
Keywords
Interns of clinical medicine Hematology department Quality of medical record