如果病人读到这封信怎么办? 一个学生指南写在GP电子病人的记录
Caroline Sprake1, Catja Schmitgen2, Juliet Brown3
1School of Medicine, Newcastle University, Newcastle, UK.
概括
医学学生从编写电子病历 (EPR) 中受益,但指导很少. 开发和评估了一份新的英国通用实践 (GP) 笔记指南,显示了价值,但需要改进访问.
科学领域:
- 医学教育 医学教育
- 数字健康记录数字健康记录
- 临床交流 临床沟通
背景情况:
- 英国全科医院 (GP) 的高级医学学生通常将咨询记录在电子病历 (EPR) 中.
- 教育方面的好处包括改善了临床记录和推理,但医学课程中缺乏关于笔记写作的正式指导.
- 自2023年10月以来,患者访问EPR,包括自由文本笔记,在英格兰是标准的.
研究的目的:
- 为医学学生开发和评估一本关于在EPR中编写有效的GP咨询笔记的指南.
- 解决临床笔记写作正式培训方面的差距.
主要方法:
- 在患者和公众参与下,英国大学医学教育临床传播委员会 (UKCCC) 共同开发了一份指南.
- 该指南向英国医学院 (2023年8月至10月) 传播.
- 实用性通过学生和GP导师调查来评估.
主要成果:
- 学生和导师发现关于内容,结构和清晰度的指导是有价值的.
- 需要改进的领域包括指南意识,移动访问和格式化.
- 对于未来版本的建议包括添加链接到学习资源.
结论:
- 开发的指南被学生和教育工作者重视为改善GP咨询笔记.
- 提高意识,可访问性 (尤其是移动设备上) 和资源对于更广泛的采用和影响至关重要.
- 根据用户反计划进一步开发,以优化指南在医学教育中的实用性.
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