McGlade Kieran, Cargo Catherine, Fogarty Damian, Boohan Mairead, McMullin Mary
School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, UK.
Clin Teach. 2012 Apr;9(2):112-8. doi: 10.1111/j.1743-498X.2011.00494.x.
This article describes a 'back to the future' approach to case 'write-ups', with medical students producing handwritten instead of word-processed case reports during their clinical placements. Word-processed reports had been found to have a number of drawbacks, including the inappropriate use of 'cutting and pasting', undue length and lack of focus.
We developed a template to be completed by hand, based on the hospital 'clerking-in process', and matched this to a new assessment pro forma. An electronic survey was conducted of both students and assessors after the first year of operation to evaluate impact and utility.
The new template was well received by both students and assessors. Most students said they preferred handwriting the case reports (55.6%), although a significant proportion (44.4%) preferred the word processor. Many commented that the template enabled them to effectively learn the structure of a case history and to improve their history-taking skills. Most assessors who had previously marked case reports felt the new system represented an improvement. The average time spent marking each report fell from 23.56 to 16.38 minutes using the new pro forma.
Free text comments from the survey have led to the development of a more flexible case report template better suited to certain specialties (e.g. dermatology). This is an evolving process and there will be opportunities for further adaptation as electronic medical records become more common in hospital.
本文描述了一种病例“撰写”的“回归未来”方法,即医学生在临床实习期间手写而非用文字处理软件撰写病例报告。已发现用文字处理软件撰写的报告存在诸多缺点,包括不当使用“剪切粘贴”、篇幅过长和缺乏重点。
我们基于医院的“入院登记流程”开发了一个需手写完成的模板,并将其与新的评估表格相匹配。在运行的第一年结束后,对学生和评估者进行了电子调查,以评估其影响和实用性。
新模板受到了学生和评估者的好评。大多数学生表示他们更喜欢手写病例报告(55.6%),不过仍有相当比例(44.4%)的学生更喜欢使用文字处理软件。许多人评论说,该模板使他们能够有效地学习病史的结构并提高病史采集技能。大多数以前批改过病例报告的评估者认为新系统有所改进。使用新表格批改每份报告的平均时间从23.56分钟降至16.38分钟。
调查中的自由文本评论促使我们开发了一个更灵活的病例报告模板,更适合某些专科(如皮肤科)。这是一个不断发展的过程,随着电子病历在医院中越来越普遍,将有机会进行进一步调整。