1Department of Respiratory and Critical Care Medicine,2Department of Ophthalmology,3Department of Second Clinical College,Tongji Medical College of Huazhong University of Science and Technology,Wuhan 430030,China
Abstract：ObjectiveIn order to further promote the abilities of medical records writing and the ability of shock rescue in the residents,meanwhile provide an evidence for the reform of clinical teaching,we investigated these abilities of the residents in current situation.MethodsTwo skills of 185 physician residents were evaluated：one was the writing of complaint and present history,the other was the treatment of shock.The result of the evaluation was descriped as correct or incorrect,with the incorrect rate calculated.ResultsAmong 185 residents,the incorrect rates of complaint writing were 94.4%,60.0% and 78.3% for the training doctors,the normative training doctors and the native doctors graduated doctors from our own medical school respectively.The total incorrect rate was 88.6%,the differences among those three groups showed statistical significance (χ2=23.39,P<0.01);there were also significant differences between the training doctors and the normative training doctors,and the native doctors (χ2=19.56,5.03;P<0.05).The average incorrect rate of the present history writing was 54.7%.In consideration of the aspects of precipitating factors,such as main symptoms and accompanying symptoms,the total incorrect rates were 92.4%,82.7% and 42.2% for the three groups respectively.There were significant differences among those three groups in each aspect (χ2=27.08,17.11,13.38;P<0.01).In the aspect of precipitating factors,the differences between the training doctors (97.2%) and the normative training doctors (65.0%) was significant (χ2=23.83,P<0.01);in the aspect of main symptoms,the differences between the training doctors (88.7%) and the normative training doctors (55.0%) or the native doctors (69.6%) were also obviously (χ2=12.81,4.57;P<0.05).The average incorrect rate of shock treatment was 52.1%.In the aspects of oxygen inhaling and vital sign monitoring,intravenous access obtaining,blood volume supplying,pH and electrolyte balancing,and medication choosing,the total incorrect rates were 46.5%,79.5%,42.7%,47.6%,and 44.3% respectively.In the aspect of oxygen inhaling and vital sign monitoring,the incorrect rate of the training doctors was 45.1%.The differences between the training doctors,the normative training doctors (55.0%) and the native doctors (47.8%) were not significant (χ2=0.70,0.06;P>0.05).The training doctors had the highest incorrect rate in the aspect of intravenous access obtaining.The normative training doctors had the highest incorrect rates in the aspects of blood volume supplying,pH and electrolyte balancing,and medication choosing, the incorrect rates were significantly different from those of the training doctors and of the native doctors (P<0.05).ConclusionThe incorrect rates of the two basic skills of the residents in medical record writing and shock treatment are both above fifty percent.To solve this problem,the reform of normative training and method of teaching evaluation is in urgent need.
左鹏 胡维琨 万宝俊 余慕清 赵建平 熊盛道. 住院医师病历书写质量和抢救休克能力现状的调查与思考[J]. 中华诊断学电子杂志, 2015, 3(4): 267-.
Zuo Peng,Hu Weikun,Wan Baojun,Yu Muqing,Zhao Jianping,Xiong Shengdao. The investigation and thinking of the status quo of the residents in medical record writing and shock treatment. zhzdx, 2015, 3(4): 267-.
