目的 探讨平行病历写作训练在妇产科住院医师规范化培训(简称住培)中的应用效果。方法 采用方便抽样方法,选取2023年6至12月西湖大学医学院附属杭州市第一人民医院妇产科23名住培学员为研究对象,开设平行病历写作训练课程,包括理论学习6学时,实践课程6学时。教学前后分别采用中文版杰弗逊同理心量表学生版对住培学员的同理心进行评分;教学后对住培学员进行问卷调查,从多个维度评价教学效果。采用配对样本t检验分析相关数据。结果 住培学员在开展平行病历写作训练前、训练后的同理心评分分别是(102.8±12.1)分和(119.4±10.6)分,其差异具有统计学意义(P＜0.001)。问卷调查结果显示,91.3%(21/23)的住培学员对该课程评价为“好”或“很好”,87.0%(20/23)的住培学员认为该课程有助于提高其同理心和医患沟通能力,91.3%(21/23)的住培学员认为该课程促进了其在临床实践中的反思。然而,56.5%(13/23)的住培学员认为该课程显著增加了学习负担。结论 平行病历写作训练有助于提升妇产科住培学员的同理心,有助于提高住培学员的医患沟通能力和临床实践反思,同时也增加了住培学员的学习负担。建议将平行病历写作训练有机融入住培的日常临床工作中,以避免增加学员的额外时间负担。

Objective To explore the effect of training in parallel chart writing for obstetrics and gynecology trainees in the standardized residency training (hereinafter referred to as residency training). Methods A convenience sampling method was employed to enroll 23 residents in the Department of Obstetrics and Gynecology at the Affiliated Hangzhou First People′s Hospital, School of Medicine, Westlake University from June to December 2023 to participate in a parallel chart writing training course, which included six academic hours of theoretical training and six academic hours of practical training. The empathy levels of the residents were assessed before and after training using the Chinese version of the Jefferson Empathy Scale - Student Version. The teaching effect was evaluated through a satisfaction questionnaire after training. The paired sample t-test was used to analyze relevant data. Results The empathy scores of the residents before and after the parallel chart writing training were 102.8±12.1 and 119.4±10.6, respectively. The difference was statistically significant (P<0.001). The questionnaire survey results showed that 91.3%(21/23) of the residents rated the course as “good” or “very good”, 87.0%(20/23) believed that the course helped improve their empathy and doctor - patient communication skills, and 91.3%(21/23) thought that the course promoted reflection in their clinical practice. However, 56.5%(13/23) of the residents felt that the course significantly increased their learning burden. Conclusions Training in parallel chart writing can enhance the empathy of residents in obstetrics and gynecology, improve their doctor-patient communication skills and clinical practice reflection. However, it also increase their learning burden. It is suggested that integrating parallel chart writing training into daily clinical work can avoid additional time costs.