Richardson Karl M, Cristiano Joseph A, Schafer Katherine R, Shen E, Burns Cynthia A
Wake Forest School of Medicine, Medical Center Dr, Winston Salem, NC 27157 USA.
Med Sci Educ. 2022 Jun 13;32(4):773-777. doi: 10.1007/s40670-022-01570-5. eCollection 2022 Aug.
With increasingly complicated patients and faster throughput, time for thorough critical thinking and thoughtful clinical documentation is limited, especially in the training environment. Advocating for the value of clinical documentation as a robust opportunity for critical thinking, we describe the implementation and evaluation of a clinical reasoning and documentation curriculum for internal medicine residents. Our curriculum employed facilitated discussion, practical application, and a resident-as-teacher model. Resident surveys showed improved perceptions of the clinical and educational value of clinical documentation. Residents reported increased feedback to interns about their documentation and more appreciation of documentation as a venue for critical thinking.
The online version contains supplementary material available at 10.1007/s40670-022-01570-5.
随着患者情况日益复杂以及诊疗效率提高,进行深入批判性思维和撰写详尽临床记录的时间有限,尤其是在培训环境中。我们倡导将临床记录视为进行批判性思维的重要契机,在此描述了一项针对内科住院医师的临床推理与记录课程的实施及评估情况。我们的课程采用了引导式讨论、实际应用以及住院医师担任教师的模式。住院医师调查显示,他们对临床记录的临床和教育价值的认知有所改善。住院医师报告称,他们对实习医生记录的反馈增多,并且更认可记录是批判性思维的一个途径。
在线版本包含可在10.1007/s40670-022-01570-5获取的补充材料。