综合医院中医病案质量分析

本文通过对中医病案书写中存在的中医辨证论治思想不清晰或记录过于简单,无法反映中医辨证思想;三级医师查房内容空洞、形式化;问诊记录不准确、四诊记录不全面;中医治疗方法简单等主要质量问题剖析,发现中医病案缺乏中医特色内涵,中医＂西化＂现象普遍存在,采取加强中医人员质量意识教育和《中医病案书写基本规范》培训;重视中医理论学习与开展特色中医临床实践相结合;利用医院病案质控网络组织,强化环节质控与严格终末质控相结合等措施,提高中医病案书写质量。

Quality Analysis of Traditional Chinese Medicine Medical Records in Comprehensive Hospital

This paper analyzed major quality problems,for example,unclear TCM syndrome differentiation or too simple record in TCM medical records writing that can not reflect TCM syndrome differentiation;empty and formalization content of three levels doctor’s ward round;incorrect inquiry record,incomplete four inquiry record and simple TCM treatment methods,which found out TCM medical records lacking of TCM characteristic connotation and existed western-medicine-trend.It suggested strengthening training of quality consciousness education of TCM staff and Basic Regulations of TCM Medical Records Writing,paying attention to the combination of TCM theoretical learning and characteristic TCM clinical practice development,using medical records quality control network organization and strengthening the combination of segment quality control and final quality control,which could improve writing quality of TCM medical records.