病歷導向小組討論會教導醫學生寫病歷及臨床推理

病歷導向小組討論會（Chart-based Group Discussion，CbGD）是以病歷刺激回憶（Chart Stimulated Recall，CSR）及病例導向討論（Case-based Discussion，CbD）為藍本，由一位臨床教師帶領4-6位實習醫學生，隨機抽出醫學生親自書寫的一份病歷做為討論的範例，藉由實物投影機將病歷投映至螢幕，再由參與者一齊逐字逐句討論範例病歷內容之創新的教學方法。討論過程中，除了可發現醫學生書寫病歷常見的缺失外，在討論基本資料之主訴及病史、身體診查、檢驗時，可教導臨床推理之直覺式及分析式思考；在討論診斷及治療時，更可藉著問題導向的病歷（Problem-Oriented Medical Record，POMR）之编號的問題（numbered problem）及主觀－客觀－評估－計畫（subjective-objective-assessment-plans，SOAP）系統性的分析病人所有的不適。病歷導向小組討論會在某大學兒童醫院已經連續實施7年，並獲得醫學生正向的回饋，值得推廣至其他學科及醫院。

關鍵字

病歷刺激回憶；病例導向討論；問題導向的病歷；臨床推理

並列摘要

Chart-based Group Discussion (CbGD) is an innovative teaching method based on Chart Stimulated Recall (CSR) and Case-based Discussion (CbD). A clinical teacher led 4-6 medical students, and randomly selected a medical record written by the students as a model for discussion. The contents of the selected medical record were projected to the screen and then the participants discussed the model chart word-by-word. Throughout the discussion, in addition to correct the common errors of medical students in chart writing, the concept of intuitive and analytical thinking of clinical reasoning could be introduced during discussing the basic information, including chief complaint, illness history, physical examination and laboratory tests. The numbered problems and subjective-objective-assess-plans (SOAP) methods in problem-oriented medical records (POMR) could replace the traditional diagnosis and treatment, and are useful for systematic analysis of all patient's illness. The Chart-based Group Discussion has been implemented in a university children's hospital for seven and has received positive feedback from medical students. It is worth promoting to other consecutive years, disciplines and hospitals.

並列關鍵字

chart stimulated recall ； case-based discussion ； problem-oriented medical record ； clinical reasoning

參考文獻

Weed LL. Medical records, patient care, and medical education. Ir J Med Sci 1964;462: 271-82.

Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:652-7.

Feinstein AR. The problems of the "problem-oriented medical record". Ann Intern Med 1973;78:751-62.

Jacobs L. Interview with Lawrence Weed, MD - The father of the problem-oriented medical record looks ahead. Perm J 2009;13:84-9.

Al-Wassia H, Al-Wassia R, Shihata S, et al. Using patients' charts to assess medical trainees in the workplace: a systematic review. Med Teach 2015;37(Suppl 1):S82-7.

國際替代計量

病歷導向小組討論會教導醫學生寫病歷及臨床推理

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