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《Chinese Medical Record》 2008-01
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The Pre-post Training of The Specification of the Documentation of the Medical Record and the Evaluation of the Result

Yang Jannan, Lei Yuechang, Li Qin, Li Shiyun, Li Ling, Fang Jinren. Chengdu Railway Central Hospital of Sichuan Province, Chengdu, 610081  
Objective To strengthen the training and the evaluation of The Specification of the Documentation of the Medical Record for the pre-post clinicians to guarantee medical security.Method To take pre-post training and closed-book examination about The Specification of the Documentation of the Medical Record for forty-seven clinical graduates with bachelor, doctoral or master degree newly recruited in public or not public in 2006 and 2007 and to do a statistical analysis on the result and then we made a contrast analysis between the result and that from 187 housemen who are doing the medical practice in the same hospital. Result (1) The scores of new clinicians in 2007 are higher than that in 2006 (P0.05); (2) generally, the result is lower than that of medicos; (3) the result of seventeen doctors with license including ten with doctoral master degree is less than that of new graduated medical students. Conclusion (1) Medical colleges should fortify the basic training and examination on the Documentation of the Medical Record, and revise the related chapters in Diagnosis according to The Specification of the Documentation of the Medical Record. (2) The Focus of quality control of the medical record should be moved from end quality control to basic and links' quality control, and we should strengthen pre-post training of the documentation the medical record, and bring the doctors' quality of the documentation of the medical record of into his or her evaluation of practical service ability. (3) Medical Administrative departments should internalize related content of The Specification of the Documentation of the Medical Record into the library of examination question for practical doctors.
【CateGory Index】: R-4
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