中医医院临床诊断有关中西医病名的浅析

Analysis of disease name of traditional Chinese medicine and Western medicine in TCM diagnosis

目的进行中西医双重诊断相关性研究，折射出病案书写和诊断水平的情况，为加强医疗质量管理提供借鉴。方法对全国中医医院医疗质量监测的100所中医医院，自2002--2005年4年的涉及呼吸、肾病、血液、肝病、妇科、肛肠、骨伤7个类别的37万余份出院病案首页，进行中西医双重诊断相关性研究。结果中西医诊断相符的病例有292707，中西医诊断不相符的病例有20455，中西医诊断存疑的病例有62228，中西医病名诊断规范化需要加强。结论我们必须加强中医医院的病案质量管理工作。

Objective To evaluate the correlation of TCM diagnosis and Western medicine diagnosis in TCM hospitals and get the ideas of the quality control of medical records and diagnosis. Methods Study on the correlation of TCM diagnosis and Western medicine diagnosis from 375 390 medical records of respiration, nephropathy, hematology, liver diseases, gynecology, anus-intestines and orthopedics departments during the year 2002 to 2005 in TCM hospitals. Results There are 292 707 records with the accordant diagnosis, 20 455 records with the inconsistent diagnosis, and 62 228 records of uncertain. The stand- ardization of TCM diagnosis and Western medicine diagnosis should be strengthened. Conclusion Some measures should be done to control the medicine records quality in TCM hospitals.