Feasibility of using the the first page data of medical records to evaluate the treatment scope for standardized residency training in pediatrics
Song Fei
Zeng Yueping
Lv Yaqi
Wang Aihua
Ni Xin
Abstract：Objective To explore the feasibility of using the data from the first page of medical records to evaluate the diagnosis and treatment range of resident physicians in our hospital's residency training base.Methods 75 resident physicians who enrolled in 2018(from June 2018 to May 2021)were included in this study,and diagnostic information on the first page of medical records of discharged patients from our pediatric training base during the same period was collected for statistical analysis.Results The hospital treatment of some diseases in the base and from the resident doctors did not meet the requirements.The overall rate of meeting the standard of the base was 91.7%,and that of the resident doctors was 82.1%.Conclusion The data on the first page of medical records can reflect the number of annual diagnosis and treatment scope of resident training bases or resident physicians,and can provide objective data support for evaluation.The hospital managers should fully stimulate the subjective initiative of resident physicians and effectively improve the data quality of the first page of medical records.
Keywords：standardized residency trainingpediatricsscope of diagnosis and treatmentfirst page of medical record
Publication Date：2025-03-19
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：4( 161-164 )