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| 研究型病历在血管外科住院医师规范化培训中的作用 |
| Application of research medical recordsinstandardizedtraining of vascular house surgeons |
| 投稿时间：2017-05-28 |
| DOI：10.3969/j.issn.1000-0399.2017.11.038 |
| 中文关键词: 研究型病历 住院医师规范化培训 |
| 英文关键词: Research medical records Standardizedresidents training Vascular house surgeon |
| 基金项目:国家自然科学基金青年项目（项目编号：81500390），第二军医大学教育研究课题基金（项目编号：JYC2016029），第二军医大学第一附属医院教育研究课题基金（项目编号：CHJG2016024） |
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| 中文摘要: |
| 目的 探讨研究型病历在血管外科住院医师规范化培训中的作用。方法 将2015年10月~2016年9月在长海医院血管外科学习的84名住院医师随机分为研究型病历组41名和传统型病历组43名,研究型病历组医师完成一份研究型病历,传统型病历组医师完成一份普通电子病历,比较两组医师在临床教学质量、临床科学研究方面的差异。结果 临床教学质量方面：研究型病历组住院医师的病历质量评分有改进75.6%,高于传统型病历组46.5%,差异有统计学意义（P=0.006）；病历资料的完整性与准确性有改进85.4%,高于传统型病历组55.8%,差异有统计学意义（P=0.003）；诊疗计划的熟知情况方面有改进80.5%,高于传统型病历组53.5%,差异有统计学意义（P=0.016）。临床科学研究方面：研究型病历组在科研数据的完整性方面有改进85.4%,高于传统型病历组58.1%,差异有统计学意义（P=0.006）；疾病诊断亚分类的准确合理性有改进82.9%,高于传统型病历组55.8%,差异有统计学意义（P=0.006）；住院医师科研思路的影响有改进80.5%,高于传统型病历组51.2%,差异有统计学意义（P=0.006）。结论 研究型病历在血管外科住院医师规范化培训中发挥积极作用,提高了临床教学质量和临床科学研究水平。 |
| 英文摘要: |
| Objective To explore the applicationeffects of research medical records in the standardized training of residents inthe vascular surgery department. Methods 84 resident doctors studying in our department between Oct 2015 and Sep 2016 were collected andrandomly divided into two groups:41 cases ofresearch (medical record) groupand 43 cases of traditional(medical record) group. Residentsin the research group were asked to finish research medical records, while residents in the traditional group were asked to finish common electrical medical records. By means of questioningin teaching ward rounds or departmental rotation examination,all house surgeons receivedevaluationabouttheir quality of clinical teaching and research. Results In aspect of clinical teaching quality, the improvement percentage of quality scoring ofmedical records in the research group (75.6%) wassignificantlyhigher than that in the traditional group (46.5%)(P=0.006), so was the improvement percentage of integrity and accuracy of medical records, and the improvement percentage of awareness of diagnosis and treatment plans, in the research group and the traditional group (85.4% vs 55.8%;80.5% vs 53.5%), with significant differencesbetween them(P=0.003;P=0.016).In aspect of clinical researchquality,higher improvement percentages of integrity of research data (85.4%), accuracy and rationality of disease diagnosis and sub-classification(82.9%), and influence onresidents'research approaches (80.5%) were found in the research group, and in comparison with those in the traditional group (58.1%;55.8%;51.2%), the differences between them were all statistically significant (all P=0.006). Conclusion Research medical records wouldplay positive roles in the standardized training of vascular house surgeons, and are worthy of clinical expansion and application. |
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