探讨临床实习的病历书写带教

临床实习中病历书写带教是非常必要的,因为实习医师缺乏临床经验和书写病历的经验,病历书写同样需要有一个从理论到实践的过程,这个过程需要由带教来完成。病历书写的带教内容主要是教会实习医师书写病历,包括书写病历对应的理论知识、书写病历的具体方法等,同时要教会实习医师分析问题和解决问题的方法。病历书写的带教方法主要是要有专人负责,并且要有详细具体的带教计划和要求,同时让实习医师不断的实践,再配合带教老师对病历的讲评。只有在临床实习中很好的进行病历书写带教,才能提高病历书写的内涵质量。

A Discussion of the Writing of Medical Records in Clinical Intern Training

It is very necessary to include the teaching of medical records writing in clinical internship.Interns are Lack of clinical experience and the experience of writing medical records.Writing of medical records is a process from theory to practice.This process should be included in interns’ training.The content of this part of the training is mainly about the writing skills of medical records.It includes related theoretical knowledge,specific methods and the abilities to analyze and solve problems.Methods include having a doctor take charge of the completed training thoroughly,detailed plans and requirements,and the feedbacks of interns’ writings from doctors in charge.Only through a better completion of the training of writing skills can interns improve their writings of medical records to a more analytical and apprehensive style.