Quality analysis of pediatric admission records by resident physicians and the guidance and teaching methods
Niu Chao
Yan Li
Ding Fengxia
Yang Ting
Li Ying
Dai Jihong
Tian Daiyin
Liu Zheng
Abstract：Objective To find the common defects of pediatric respiratory admission records by resident physicians,and to provide guidance and teaching methods for standardized residency training.Methods A total of 60 pediatric respiratory admission medical records,which were written by 21 resident physicians from September 2021 to February 2022,were analyzed to find the common defects.Guidence teachers analyzed the quality of admission records,guided the residents to analyze and deal with the defects in the medical records,and taught resident physicians to diagnose the disease and write the medical records.Results Common defects made by resident physicians in writing the admission history covered all sections of the admission record,among which the history of present disease,growth history,physical examination and diagnosis were the most common error parts.It needed to be strengthened in the diagnosis and treatment of the diseases,medical thinking and legal awareness for resident physicians.Conclusion By analyzing the common defects of pediatric respiratory admission records written by residents,this study provides guidance and teaching methods,which may not only be used to reduce the defects of admission records,but also show more humanistic care among medical colleagues.
Keywords：standardized residency trainingadmission recordspediatricsrespiratory department
Publication Date：2024-07-20
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：5( 492-496 )