目的 分析外科病历的特点及医学生书写的常见问题,以提高医学生临床技能,促进外科临床教学.方法 总结912份北京协和医院外科医学生书写的住院病例,分析其常见问题,结合外科病历的特点,提出外科病例书写教学的方法与对策.结果 病历集中体现出一些共性问题,例如现病史与病历特点书写冗长重复,专科查体不完善,拟诊讨论简单、欠缺条理性等.结论 外科病历书写有其独特特点,应详细分析并结合这一特点,以规范性、条理性和完整性的原则指导外科病历书写.%Objective Evaluate the features of the surgery medical record and the common problems the medical students had in writing it, so as to improve clinical teaching of the surgery department and streng then the clinical skills of the students. Methods 912 cases of medical records written by the interns of PUMC hospital were summarized. The common problems and weakness were evaluated. Combined with the features of surgical medical records, the methods and strategies in surgical medical records teaching are proposed. Results There were some common problems in the 912 cases of medical records. The medical history and case characteristic were too long with over laping contents. The physical examination is incomplete. The diagnosis discussion is too simple with poor logistic thinking. Conclusion The writing of surgical medical records has its special reguirements, which should be evaluated in detail during the teaching and training of medical students. Combined with these requirements, the surgical medical records should be prepared in a standardized procedures.
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