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

Abstract

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

CLC Number:

R783

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.

Figures/Tables 5

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References 21

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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

To explore the application of SP-based medical record writing training in prosthodontics practice

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