关键词: 病例总结能力, 评价指标, 住院医师, 有效性

Abstract: Objective To develop a rubric to assess the ability of case summary of residents, and verify its validity. Methods In this study, the literatures combined with Delphi method were used to develop a rubric to assess the ability of case summary of residents.A total of 90 hospitalized cases of gastroenterology from the electronic medical record system in the First Affiliated Hospital of Anhui Medical University were selected by random number table method.The three raters scored according to the assessment rubric respectively. Cronbach coefficient was used to determine the internal consistency of five assessment criteria, the intraclass correlation coefficient (ICC) was used to determine the interrater agreement, and the Spearman rank correlation coefficient was used to determine the correlation among the five assessment criteria. Results After literature research and expert consultation, the assessment rubric of case summary ability was clarified,including 5 items of accuracy of clinical information, appropriate narrowing of differential diagnosis, translation of medical terms, use of semantic qualifiers, and global rating of clinical information summary.TheCronbach′s α coefficient of the second expert consultation questionnaire was 0.823 and the content validity index was 0.960.TheCronbach′s α coefficient of the assessment rubric was 0.801. The ICC of every item was 0.834, 0.690, 0.796, 0.802 and 0.760, respectively. The Spearman rank correlation coefficients for translation of medical terms and appropriate narrowing of differential diagnosis and global rating of clinical information summary are 0.71 and 0.69. Conclusions The assessment rubric of case summary ability of residents based on Delphi method has good reliability and validity. The assessment rubric has high internal consistency and inter-rater consistency.Its validation has been preliminarily verified in clinical practice.    

Key words: The ability of case summary, Assessment rubric, Resident, Validity