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.
Li Chengyu
,
Li Xiaowei
,
Ye Ziguan
,
Xu Pusheng
,
Xu Miqing
. The common mistakes and recommendations in writing progress note[J]. Chinese Journal of Medical Education, 2019
, 39(5)
: 367
-370
.
DOI: 10.3760/cma.j.issn.1673-677X.2019.05.011
[1]杨坤,廖有乔.医学实习生病程记录书写的教学探讨[J].中国病案,2012,13(2):42,封2.DOI:10.3969/j.issn.1672-2566.2012.02.025.
[2]陈敏,陈合辉.病程记录书写存在的缺陷分析[J].临床医学工程,2012,19(8):1399-1400.DOI:10.3969/j.issn.1674-4659.2012.08.1399.
[3]中华人民共和国卫生部医政司,编.病历书写基本规范[M].北京:科学出版社,2010: 7-8.
[4]高华,李焱莎,王书抗.病程记录书写缺陷原因分析及建议[J].中国卫生质量管理, 2012,19(3):44-46.