医学生对病历书写基本规范的认知差异及干预研究

为提高医学生病历书写技能、掌握病历书写要求和法律规定,本研究以《侵权责任法》第七章医疗损害责任和《病历书写规范》为依据,评估、干预、提高医学生的病历书写技能和法律意识。结果显示,实习生与在校生有统计学差异,干预前后的在校生对病历书写规范及医疗损害法律制度的认知有统计学差异。研究认为,在校生经针对性、综合性、规范化的病历书写规范培训后,能有效掌握病历书写规范的要求和法律制度。建议病历书写规范的培训应该常规化、制度化、规范化,纳入教学计划,提高医学生的病历书写技能和法律意识,减少病历记录不良和记录瑕疵,防范医疗纠纷。

Intervention and cognitive difference of medical students on medical record writing standard

The objective of this research is to improve the medical students＇ medical records writing skills and master the medical record writing requirements. According to Tort Liability Law＇s seventh chapter of medical damage liability and the Medical Record Writing Standard , this research try to evaluate, intervene and improve medical students＇ medical records writing skills and legal consciousness. The Result shows that internal students and students at school have significant difference, and the students＇ record writing standard and legal system of medical damage have cognitive differences before and after intervention. This research found that students can effectively hold the record writing standard requirements and legal system, who get the targeted, comprehensive, standardized medical record writing standard training. We suggest that records writing training should be routine, institutionalization, standardization and bring into the teaching plan, to improve medical students＇ medical records writing skills and awareness of the law, and to reduce the medical record bad and recording defect, also to prevent medical disputes.