探讨基于标准化患者的病历书写训练在口腔修复实习中的应用

doi:10.13591/j.cnki.kqyx.2025.02.009

摘要/Abstract

摘要：

目的评价基于标准化患者(standardized patients,SP)的病历书写训练的实践效果,探讨其在口腔修复学实习中的应用。方法将71名本科实习生随机分为2组,实验组(n=35)采用基于SP的病历书写训练,训练结束后通过问卷调查学生对教学效果的评价;对照组(n=36)采用传统讲授式的病历书写培训。1周后两组进行同样的病历书写考核。比较不同教学方式的病历书写评分,并统计实验组学生对教学效果的评价。结果考核时实验组病历书写评分(88.80±4.60)分显著高于对照组(84.92±5.51)分,差异有统计学意义(P=0.002)。实验组88.57%学生对基于SP的病历书写训练很满意,满意度评分为8.94分。结论病历书写训练是一项长期的临床实践,基于SP的病历书写训练有利于提高医学生的病历书写质量。

关键词: 病历书写, 标准化患者, 口腔修复学, 本科实习生

Abstract:

Objective To evaluate the practice effect of medical record writing training based on standardized patients and explore its application in prosthodontics practice. Methods Seventy-one undergraduate interns were randomly divided into two groups. At the first week of clinical practice, the test group(n=35) adopted the SP-based medical record writing training, and after the training, the students’ evaluation of the teaching effect was investigated by questionnaire. And the control group(n=36) received traditional lectured medical record writing training. One week later, the same medical record writing exam was performed in the two groups. The scores of medical record writing of different teaching model were compared, and the evaluation of the teaching effect in the test group was carried out. Results The exam score of medical record writing of the test group (88.80±4.60) was significantly higher than that of the control group (84.92±5.51), and the difference was statistically significant(P=0.002). 88.57% of the students in the test group were satisfied with the SP-based medical record writing training. The satisfaction score was 8.94. Conclusion Medical record writing training is a long-term clinical practice. SP-based medical record writing training is helpful to improve the medical record writing quality of medical students.

Key words: medical record writing, standardized patients, prosthodontics, undergraduate interns

中图分类号:

R783

李雪铃, 江柳霖, 姚依彤, 浩志超, 吴茂丹, 邓晓怡, 杨凌. 探讨基于标准化患者的病历书写训练在口腔修复实习中的应用[J]. 口腔医学, 2025, 45(2): 129-133.

LI Xueling, JIANG Liulin, YAO Yitong, HAO Zhichao, WU Maodan, DENG Xiaoyi, YANG Ling. To explore the application of SP-based medical record writing training in prosthodontics practice[J]. Stomatology, 2025, 45(2): 129-133.

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时间	实验组 (n=35)	对照组 (n=36)	t	P
情景教学当天	90.90±3.90	90.71±2.75	0.240	0.811
1周后考核	88.80±4.60	84.92±5.51	3.217	0.002^*
t	2.535	5.382
P	0.016^*	0.000^*

时间	评分($\bar{x}±s$)	t	P
情景教学当天	90.90±3.90	t_(1,2)=3.002	P_(1,2)=0.005^*
SP训练当天	93.83±4.13
考核评分	88.80±4.60	t_(2,3)=5.871	P_(2,3)=0.000^*

书写内容	对照组(n=36)		实验组(n=35)
书写内容	情景教学当天	考核	情景教学当天	SP训练当天	考核
主诉(缺陷)	0.00	5.56	2.85	8.57	22.86
现病史(缺陷)	2.78	25.00	0.00	17.14	22.86
既往史(缺陷)	47.22	58.33^*	62.86^*	71.43^*	22.86
面部外形(缺失/缺陷)	33.33	33.33	28.57	0.00	8.57
颞下颌关节情况(缺失)	0.00	88.89^*	0.00	0.00	65.71^*
咀嚼肌情况(缺失)	86.11^*	97.22^*	71.43^*	22.86	85.71^*
下颌运动情况(缺失)	0.00	91.67^*	0.00	5.71	71.43^*
缺牙部位情况(缺陷)	30.56	52.78^*	37.14	17.14	11.43
余留牙情况(缺陷)	5.56	30.56	22.86	8.57	20.00
修复体/充填物情况(缺陷)	94.44^*	5.56	68.57^*	2.86	0.00
软组织情况(缺失/缺陷)	33.33	94.44^*	37.14	31.43	82.86^*
咬合情况(缺失)	5.56	25.00	14.29	31.43	22.86
口腔卫生情况(缺失/缺陷)	75.00^*	25.00	74.29^*	20.00	25.71
阴性体征和辅助检查结果(缺失/缺陷)	58.33^*	47.22	65.71^*	48.57	20.00
诊断或鉴别诊断(缺陷)	55.56^*	58.33^*	57.14^*	74.29^*	65.71^*
治疗意见/过程(缺陷)	86.11^*	88.89^*	48.57	57.14^*	80.00^*
医师签名(缺失)	5.56	13.89	5.71	8.57	2.85

调查内容	1~4分	5~7分	8~10分	平均分
对SP训练的满意度	0%	11.43%	88.57%	8.94
SP训练有利于提升学习兴趣	0%	17.14%	82.86%	8.63
SP训练有利于加强理论知识的掌握	0%	14.29%	85.71%	8.77
SP训练有利于增强接诊和病历书写的信心	0%	17.15%	82.86%	8.69
学会了书写主诉、现病史、既往史	0%	34.29%	65.72%	8.26
学会了有逻辑性地书写专科检查结果	0%	54.29%	45.72%	7.54
学会了正确的诊断	0%	51.43%	48.57%	7.57
学会了制定治疗计划	0%	57.15%	42.86%	7.43