Analysis of pediatric interns＆#39; writing defects of medical records and countermeasures

Abstract

In order to improve the quality of medical record written by pediatric interns, the defects of 535 medical records written by pediatric interns were analyzed. The main reasons affecting the quality of medical record written by pediatric interns were found： writing defects among history of present illness,physical examination and personal history. At present, many factors have caused the deficiencies of medical record writing, such as the factor of low-level teachers, the lag of the teaching management, the particularity of pediatric practice, and students’ lack of training in school. So some countermeasures have been suggested：firstly, importance should be attached to the construction of the teaching staff. Measures should be taken to inspire the teachers to work more actively with a serious and responsible attitude. With a solid clinic and teaching skills, teachers can use a variety of methods properly. The management of teaching should be enforced. A variety of means can be used to improve the interns’ clinical thinking and language expression ability , to establish and improve the medical quality control system of the interns constantly, to make use of pre job training and education reason-ably, to strengthen the intern’s legal ideas, to straight their internship attitude, and to help them to adapt to the pediatric practice environment as soon as possible. At last, measures should be taken to cultivate interns’ interrogation, physical examination and patient communication skills actively and reform the school education to meet the needs of clinical development as well. Key words: Pediatric teaching; Interns; Defects of medical records