Exploration of Training Methods and Effects for Initial Medical Record Documentation Combined with Clinical Thinking
To explore the effectiveness of training methods for initial medical record documentation when combined with clinical thinking,and to assess their impact on the quality of medical record writing.This study involved training for interns on initial medical record documentation using different guidance methods.The training incorporated regular clinical teaching practices and evaluations of medical record modifications.The quality of medical records and the interns'abilities in clinical comprehensive thinking and patient communication were assessed.The training methods that integrated clinical thinking significantly improved the quality of medical records,enhanced the interns'comprehensive clinical thinking abilities,and improved their humanistic communication skills with patients.Incorporating clinical thinking into the training for initial medical record documentation effectively enhances the writing quality of medical records,and contributes to better clinical thinking and patient communication skills among medical students.
Initial Medical Record DocumentationClinical ThinkingJob Competency
NETL
NSTL
万方数据
