如何书写好内科病历

病历是医疗活动的原始记录或历史记载,是最准确,可信的记录。在现代医院管理中,病历作为医疗活动信息的主要载体,不仅是医疗、教学、科研的第一手资料,而且也是综合评价医院医疗质量、技术水平、管理水平的依据。即病历质量好坏体现医生的学术和品德,体现医院的管理水平和医疗质量。病志书写的水平,是一位医生理论基础、技术水平、临床经验、表达能力、逻辑思维的综合检验。然而现在有些病历,特别是大医院的病历质量不高的原因是工作太忙,病人太多。下级医师对疾病特点了解不够,概念不清楚。上级医师要养成习惯把您心里想的思路说出来,以提问的方式讲更好,这样对下级医生的印象会更深,同时也可以掌握他们是否理解正确了,督促下级医生平时的学习,始终要抓"三基三严",强调临床基本功。本文把内科病历书写中的常见问题一一列出,并具体指导如何改进。     

从《病历书写基本规范》的施行谈对患者同意权的再认识

本文通过对《病历书写基本规范》中有关患者同意权内容的研究,重点探讨了患者同意权的应用范围、发展变化以及尚需进一步解答的具体问题。为在实践中充分领会"《规范》"内容,不断深化患者权益保障,促进医院管理水平稳步提高作出了笔者力所能及的贡献。     

双轨病历构建

医学实践内容不断扩展,以身体哲学为基础的人文医学进路逐渐清晰,现有标准化病历却没有人文医学空间,需要重新构建双轨病历。双轨病历包含人文医学实践与生物医学实践,是病历管理模式的必然方向。双轨病历的记录内容、记录方式,将成为医学现阶段的一个重要研究课题。在分析生物医学病历书写与叙事医学病历书写之后,全面设计双轨病历,目的是使人文医学与生物医学的实践有机相融,完整、全方位记录全人医学实践。实现双轨病历的关键基础是借助信息技术,利用人文医学本体,智能化记录医学实践是未来的发展方向。

     

累积生态风险与青少年的学业和社交能力：子女责任感的风险补偿与调节效应

以613名青少年（平均年龄13.96岁,女生372人）为被试,考察子女责任感在累积生态风险与男、女生学业能力和社交能力关系中的风险补偿与调节效应。多重回归分析表明：（1）累积生态风险对男、女生的学业能力、社交能力都具有显著的负向预测作用;（2）子女责任感可以正向预测累积生态风险背景下女生的学业能力以及男生的社交能力,因此具有风险补偿效应;（3）子女责任感在累积生态风险与女生学业能力之间起“风险缓冲”作用,在累积生态风险与女生社交能力的关系中却具有“风险增强”作用,出现了“韧性代价”的现象;（4）子女责任感在累积生态风险与男生学业能力、社交能力关系中的调节效应均不显著。以上结果初步表明,某些处境不利儿童的健康发展可能存在代价,对逆境儿童的韧性发展可能不宜过分乐观。     

Cumulative Adversity as a Correlate of Posttraumatic Growth: The Effects of Multiple Traumas,Discrimination, and Sexual Harassment

While trauma is, by definition, a necessary precursor of posttraumatic growth, other aspects of individuals’ life experiences affect their ability to cope with trauma, foster resilience, and grow following adversity. Most research on posttraumatic growth overlooks the accumulation of trauma and sub-trauma stressors as possible predictors of growth. In addition, most research on cumulative adversity omits all but the most extreme examples of discrimination and sexual harassment stressors. This exploratory study of 46 university students with trauma histories used measures of posttraumatic growth, trauma, major (sub-trauma) life events, chronic stressors, sexual harassment, and discrimination to examine the relationship between cumulative adversity and the development of posttraumatic growth. We found that cumulative adversity is positively correlated with posttraumatic growth, and that there are important relationships between gender, race, and cumulative adversity. A hypothesized curvilinear relationship between cumulative adversity and posttraumatic growth was not supported. These findings suggest that successfully coping with some amount of sub-trauma adversity may facilitate the development of posttraumatic growth. Additionally, sexual harassment and discrimination were closely linked to the number of chronic stressors; thus, they need to be included in measures of cumulative adversity to more fully represent the experiences of marginalized groups.     

Psychological distress in patients with chronic atrophic gastritis: the risk factors,protection factors,and cumulative effect

This study aimed to examine the psychological status among Chronic Atrophic Gastritis (CAG) patients and to find the cumulative effects of risk and protective factors. A sample of 101 CAG patients completed the investigation. Hierarchical linear regression was used to find risk and protective factors, and examine the cumulative effects in risk factor index (RFI) and protective factor index (PFI). Results showed that nine symptoms from SCL-90-R were severer among CAG patients than those in adult norm. Risk factors including positive family history of cancer and higher negative life events could predict higher GSI (β = 0.206, p = 0.023; β = 0.398, p < 0.001; R² = 0.203); more household resistant, positive coping and stronger resilience were protective factors and could predict GSI negatively (β = -0.188, p = 0.020; β = -0.350, p = 0.012; β = ?0.066, p = 0.621; R² = 0.190). The GSI was positively correlated with RFI (β = 0.338, p < 0.001; R² = 0.113) and negatively related to PFI (β = ?0.378, p < 0.001; R² = 0.133). In conclusion, CAG patients suffered from various psychological distress, and the protective factors should be enhanced cumulatively to protect against psychological distress.     

累积情境风险与流动儿童主观幸福感的关系:个体保护因子的补偿效应和保护效应

对511名初二年级的流动儿童（平均年龄：14.37±0.78岁）及其家长进行问卷调查,考察累积情境风险与流动儿童主观幸福感的关系,及自尊、心理弹性和情绪调节等个体保护因子的作用方式差异及累积效应。结果发现：（1）累积情境风险负向预测流动儿童主观幸福感,各领域风险预测作用由大到小依次是家庭关系风险、同伴风险和学校风险,家庭社会经济地位风险预测作用不显著;（2）自尊在各领域风险与主观幸福感的关系中均发挥补偿效应;心理弹性在同伴、学校领域风险中发挥补偿效应,在家庭关系领域风险中发挥保护效应;情绪调节仅在同伴领域风险中发挥保护效应;（3）个体面临的风险数越多,具备的保护因子数越少,流动儿童主观幸福感越低。     

The impact of contextual family risks on prisoners' children's behavioural outcomes and the potential protective role of family functioning moderators

Abstract

Research suggests that children of prisoners have an increased risk for behavioural and emotional problems. However, in a resilience approach, one should expect heterogeneous outcomes and thus apply a contextualized perspective. As this is rarely acknowledged in empirical research, the present study sought to fill this gap using data from the Fragile Families and Child Wellbeing study on 801 children of imprisoned fathers. We explored the extent to which cumulative family risks measured during the first year of life (e.g., poverty and mental health problems) predicted behavioural outcomes at age 9 and whether potentially protective aspects of family functioning moderated the impact of these risk factors. Cumulative risk significantly predicted behavioural outcomes, but the associations were weak. No strong evidence of moderation was found. At low risk, mother–child closeness moderated behavioural outcomes. There was also some evidence of moderation by accumulated protective factors. Potential implications for policy and practice and challenges for further research are discussed.     

早期累积家庭风险对青少年内化问题的影响：弹性双重机制

为了解早期累积家庭风险因素对青少年内化问题的影响及其心理机制,采用累积家庭风险问卷、个人成长主动性问卷、领悟社会支持问卷以及青少年内化问题问卷对780名青少年进行调查。结果表明：（1）累积家庭风险对青少年内化问题具有显著的正向预测作用;（2）累积家庭风险因素还通过个人成长主动性和领悟社会支持的中介作用影响青少年内化问题。研究结果有助于揭示累积家庭风险对青少年内化问题的影响机制,对预防以及减少青少年内化问题行为具有一定的启示作用。     

累积生态风险对农村初中生攻击行为的影响：有调节的中介模型

本研究旨在探讨累积生态风险与农村初中生攻击行为之间的关系,以及道德推脱的中介作用与共情的调节作用。通过对845名农村初中生进行问卷调查,结果发现：（1）农村初中生累积生态风险、道德推脱与攻击行为两两之间均存在显著正相关;（2）道德推脱在累积生态风险与农村初中生攻击行为之间起部分中介作用;（3）共情调节道德推脱在累积生态风险与攻击行为之间的中介效应,相对于共情水平较高的农村初中生,中介效应在共情水平较低的农村初中生中更显著。