医学教育管理 ›› 2020, Vol. 6 ›› Issue (6): 581-585.doi: 10.3969/j.issn.2096-045X.2020.06.014

• 毕业后教育 • 上一篇    下一篇

结构式报告在耳鼻咽喉科住培医师内镜规范化培训中的应用价值

庄惠文,  陈德华,  吴  旋,  王仙仁,  江广理   

  1. 中山大学附属第一医院耳鼻咽喉科/中山大学耳鼻咽喉科学研究所,广州  510080
  • 收稿日期:2020-03-27 出版日期:2020-12-20 发布日期:2021-01-05
  • 通讯作者: 吴旋

Preliminary study on structured report in standardized endoscopic training for otolaryngology residents

Zhuang Huiwen, Chen Dehua, Wu Xuan, Wang Xianren, Jiang Guangli   

  1. Department of Otorhinolaryngology, the First Affiliated Hospital Sun Yat-sen University/Institute of Otorhinolaryngology, Sun Yat-sen University, Guangzhou 510080, China
  • Received:2020-03-27 Online:2020-12-20 Published:2021-01-05

摘要: 目的  探讨结构式报告在耳鼻咽喉科住院医师规范化培训(以下简称住培)中内镜学习的应用价值。方法  选取中山大学附属第一医院30名住培医师为研究对象,随机分为试验组和对照组。试验组采用结构式报告模板进行操作及书写培训,对照组采用自由文本方式进行培训。由不清楚分组的第三方人员抽查报告并进行质量测评,分析两组内镜报告内容差异。结果  试验组在报告内容的完整性、结构描述准确性、专业术语准确性以及鉴别诊断的实用性方面都优于对照组(P<0.05),在病变描述准确性方面,两组无明显差异(P≥0.05)。在知识要点掌握度方面试验组明显优于对照组,但操作强度也强于对照组(P<0.05)。结论  采用结构式报告有利于耳鼻咽喉科住培医师内镜学习的规范化,可以为熟悉解剖、认识病变以及提高规范的临床报告书写能力提供良好平台。

关键词: 耳鼻咽喉头颈外科学,  结构式报告,  内镜,  医学教育,  住院医师规范培训

Abstract: Objective  To explore the application value of structured report in the standardized endoscopic training of otorhinolaryngology residents. Methods  Thirty residents from the First Affiliated Hospital of Sun Yat-Sen University were selected and divided into experimental group and control group. The experimental group was trained in operation and writing using structured report templates, while the control group adopted free text. The third party, unaware of the grouping, shall spot check the reports and conduct quality evaluation to analyze the differences between the two groups. Results  The experimental group was better than the control group in terms of the completeness of report content, the accuracy of structure description, the accuracy of professional terms and the practicability of differential diagnosis (P<0.05). There was no significant difference in the accuracy of disease description between the two groups (P≥0.05). The experimental group was significantly better than the control group in the mastery of knowledge points, but the operation intensity was also stronger than the control group (P<0.05). Conclusion  The use of structured reports is conducive to the endoscopic standardization among otolaryngology residents. It can provide a good platform for getting familiar with anatomy, understanding lesions and improving the writing ability of standardized clinical reports.

Key words: otolaryngology head and neck surgery, structured reports,  endoscopic, medical education, standardized training of residents 

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