关键词: 病程记录, 错误, 建议

Abstract: Writing progress note accurately has been challenging for new residents. The most frequently seen mistakes including lacks of analyzing, copying blindly, incomplete information recording, misinterpretation of instructions from supervisors and delayed recording. The causes of these mistakes varied. On one hand, there are subjective reasons that the residents underestimated its importance or lacking motivations to do it well. On the other hand, objective reasons are also common such as weak medical knowledge comprehension, lack of supervision and overburdened in work. To resolve these problems, there are some recommendations would be helpful, which are to educate for correct motivation, to encourage them to be diligent and inquisitive, to supervise them with more instructive advices and to reduce their workloads reasonably.

Key words: Progress note, Mistake, Recommendation