目的 探讨麻醉病例信息呈现格式化模板及其软件对麻醉病例汇报教学效果的影响。方法 选取2021年7至8月在哈尔滨医科大学附属第四医院进行住院医师规范化培训(简称住培)的60名学员为研究对象,采用随机数字表法将其分为试验组和对照组。试验组31名学员采用麻醉病例信息呈现格式化模板软件收集病例资料,对照组29名学员采用传统方法收集病例资料。采用第8周测试和结业考试的病例汇报文本考核、病例汇报口述考核和问卷调查结果对两组教学效果进行评价。采用独立样本t检验和χ²检验进行两组间比较。结果 试验组学员第8周病例汇报文本考核和口述考核成绩分别为(93.1±1.5)分和(87.9±4.9)分;对照组学员第8周病例汇报文本考核和口述考核成绩分别为(73.1±5.9)分和(68.9±7.7)分,其差异均具有统计学意义(均P＜0.05)。进行2周补充教学后,于第10周进行结业考试,试验组学员病例汇报文本考核和口述考核成绩分别为(93.3±3.2)分和(88.2±4.2)分,对照组学员病例汇报文本考核和口述考核成绩分别为(94.1±2.2)分和(87.6±8.4)分,其差异均无统计学意义(均P＞0.05)。问卷调查结果显示,两组的学员均认为麻醉病例信息呈现格式化模板对提高拟讨论病例的信息呈现完整性、临床麻醉管理的水平、有效掌握基础知识等方面“非常有帮助”。结论 与传统收集病例资料的方法相比,使用麻醉病例信息呈现格式化模板收集病例资料能够促进学员对麻醉病例汇报的掌握,为麻醉病例相关教学的顺利开展打下基础。

Objective To explore the influence of anesthesia case data collection template and its software on the teaching effect of anesthesia case report. Methods Totally 60 residents who were enrolled from July to August in 2021 at Anesthesia Department in the Fourth Affiliated Hospital of Harbin Medical University. The resident trainees were randomized divided into the experimental group (n=31) and the control group (n=29). Residents in the experimental group used anesthesia case data collection template software to collect case data, while residents in the control group used traditional methods to collect case data. The teaching effects were evaluated by writing report evaluation, oral report evaluation and the questionnaire survey. Comparisons between groups were performed using independent samples t-test and χ² test. Results The score of writing report evaluation and oral report evaluation of eighth text in the experimental group were (93.1±1.5) and (87.9±4.9),while in the control group were (73.1±5.9) and (68.9±7.7). The differences were significant(all P＜0.05). The score of writing report evaluation and oral report evaluation of final test in the experimental group were (93.3±3.2) and (88.2±4.2),while in the control group were (94.1±2.2) and (87.6±8.4),the differences were not significant(all P＞0.05). The questionnaire results showed that all of the residents believed that the template-based learning was “very helpful” in improving the completeness of the case report, the level of clinical anesthesia management and the mastery of basic knowledge. Conclusions Compared with traditional methods to collect case data, using anesthesia case data collection template software to collect case data can promote the residents to master the introduction of anesthesia cases, improve the initiative of learning, and lay the foundation for the smooth development of further teaching related to anesthesia cases.