Exploration of teaching in medical record writing training:transitioning from formal frameworks to connotative content
Xu Jie
Chen Meiyi
Li Deng
Zhao Min
Wang Yi
Chen Yangxin
Abstract：Objective To apply the electronic medical record system to train resident doctors in medical record writing,explore a new method for resident doctors'medical record writing training,and focus on enhancing the connotation of resident doctors'medical record writing.Methods 59 first-year residents who was enrolled in 2020.in the orthopedic base of Sun Yat Sen Memorial Hospital were divided into teaching reform group(n=31)and control group(n=28).The teaching reform group accepted standard medical record teaching,comparison teaching and actual medical record writing.The control group received routine teaching activities.Theoretical test and medical record writing evaluation were conducted before and after the training.Results The teaching reform group and the control group showed no significant differences in pre-training theoretical test scores and medical record writing scores(all P>0.05).After the training,the teaching reform group scored higher than the control group in the total scores of the theoretical test and case analysis,with statistical significance(all P<0.05).Additionally,the teaching reform group also achieved higher scores in the total medical record writing and admission record writing than the control group,which were also statistically significant(all P<0.05).Conclusion The connotative teaching of medical record writing based on the application of electronic medical record system can promote residents to flexibly use the electronic medical record system and cultivate their ability of independent thinking and clinical thinking.
Keywords：orthopedic surgerystandardized residency trainingmedical record writingelectronic medical record system
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：5( 189-193 )