如果病人读到这个怎么办?一个学生指南,在全科医生的电子病历中写作。

IF 1.5 Q3 PRIMARY HEALTH CARE
Education for Primary Care Pub Date : 2025-01-01 Epub Date: 2024-12-17 DOI:10.1080/14739879.2024.2435613
Caroline Sprake, Catja Schmitgen, Juliet Brown, Janet Lefroy, Sarah Graham, Sarah Shepherd, Louise Smith, Louise Ward, Andrew Ward, Jon Ward, Katharine Weetman
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引用次数: 0

摘要

背景:在英国全科医学专业的高年级医学生中,将他们的咨询细节输入电子病历(EPR)是一种常见的做法。有证据表明,通过学习如何做好临床记录和提高临床推理能力,学生从写病历中受益。在英国,自2023年10月31日起,患者可以完全访问他们的EPR,包括他们咨询的免费文本笔记。尽管高质量的会诊记录很重要,但在病历中书写的指导很少包括在医学课程中。方法:在患者和公众的参与下,UKCCC(英国本科医学教育临床交流委员会)为学生制定了一份关于在患者全科医生(GP)笔记中写作的指南,并于2023年8月至10月向所有英国医学院分发。结果:通过对学生和GP导师的调查来评估指南的有效性。学生和临床教师重视咨询笔记的内容、结构和清晰度方面的指导。缺乏对指南的认识以及移动设备上的次优访问和格式被认为是需要改进的领域。其他调查反馈建议增加学习资源的链接,这将为下一个版本的开发提供信息。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
What if the patient reads this? A student guide to writing in the GP electronic patient record.

Background: It is common practice for senior medical students in UK General Practice to enter details of their consultations into the electronic patient record (EPR). There is evidence that students benefit educationally from writing in patient records through learning how to make good clinical entries and enhancing their clinical reasoning. In England, since 31 October 2023, patients are given full access to their EPR, including free text notes on their consultations. Despite the importance of high-quality consultation notes, guidance on writing in the patient record is rarely included in medical curricula.

Approach: With patient and public involvement, the UKCCC (UK Council for Clinical Communication in Undergraduate Medical Education) developed a guide for students on writing in patients' General Practice (GP) notes and disseminated it to all UK medical schools from August to October 2023.

Results: The utility of the guide was evaluated via student and GP tutor surveys. Students and clinical teachers valued the guidance on content, structure, and clarity of consultation notes. A lack of awareness of the guide and suboptimal access and formatting on mobile devices were raised as areas for improvement. Other survey responses, which will inform the development of the next version, suggested adding links to learning resources.

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来源期刊
Education for Primary Care
Education for Primary Care PRIMARY HEALTH CARE-
CiteScore
2.30
自引率
15.40%
发文量
51
期刊介绍: Education for Primary Care aims to reflect the best experience, expertise and innovative ideas in the development of undergraduate, postgraduate and continuing primary care education. The journal is UK based but welcomes contributions from all over the world. Readers will benefit from the broader perspectives on educational activities provided through the contributions of all health professionals, including general practitioners, nurses, midwives, health visitors, community nurses and managers. This sharing of experiences has the potential for enhancing healthcare delivery and for promoting interprofessional working.
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