迷失在翻译中:揭示医学学生在医学史文档中所犯的错误
Silvan Lange1,2, Nils Krüger1, Maximilian Warm1,3
1Institute of Medical Education, LMU University Hospital, LMU Munich, Munich, Germany.
The clinical teacher
|March 4, 2024
概括
医学学生在记录患者访谈时往往忽略了一些细节,这凸显了需要改善医疗史记录和报告方面的培训. 这项研究揭示了文件完整性的重大缺陷,特别是关于过敏和相关负面的缺陷.
科学领域:
- 医学教育 医学教育
- 临床技能评估 临床技能评估
- 医疗信息学 医疗信息学
背景情况:
- 准确的病史记录对于患者护理和医学教育至关重要.
- 临床病房的分散记录实践阻碍了对学生绩效的系统评估.
- 需要一种标准化的方法来评估医学学生的病史报告的完整性.
研究的目的:
- 评估医学学生记录的历史采访中遗漏的细节的程度.
- 建立在标准化的教育环境中对文档质量进行系统的评估.
主要方法:
- 一项前性观察性研究,涉及123名学生在客观结构化临床检查 (OSCE) 期间.
- 使用定性内容分析开发一个分类系统,包括9个主要类别和61个子类别.
- 将面试成绩单中的项目 (基本真相) 与学生报告中的项目进行比较,以量化文档完整性.
主要成果:
- 与基本真相相比,学生报告的完整性达到65.6% (8943项对5870项).
- 在"个人信息" (94.2%) 中发现了很大的重叠,但在"过敏"文档中发生了显著的差异 (41.1%的重叠).
- 相关的负面发现和非数值量化经常被学生遗漏.
结论:
- 医学学生展示了对患者采访的不完整文件.
- 显然需要强调和教导准确的文档作为医学教育的核心目标.
- 标准化评估工具对于监控和改进文档技能至关重要.
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