中医病案的内涵质量管理

Intensional Quality Management of Traditional Chinese Medicine Medical Record

重点针对中医内涵质量进行监控管理,能够有效提高中医病案质量。结合2010年国家中医药管理局颁布的《中医病历书写基本规范》中的有关要求,通过总结广安门医院7012份环节病历中存在的中医内涵质量方面的缺陷,归纳出中医病案内涵质量存在着望闻问切四诊信息记录不全,中医辨病辨证依据内容简单,上级医师查房记录中无中医内容或简单空洞、形式化等具体问题,提出中医病案内涵质量要求,细化病历书写切入点,强化三级病历管理网络作用,加强病历质量考核的力度,多措并举,进而提高中医病案的内涵质量。

Through stressing the monitoring management on intensional quality of traditional Chinese medicine, can we expect to improve the quality of medical record effectively. Combined with related requirements in ＂Basic Norm of Traditional Chinese Medicine Medical Record Writing＂ promulgated by the State Administration of Traditional Chinese Medicine in 2010. To summarize the defects in the intensional quality of 7012 cases of traditional Chinese medicine medical records, we generalize the specific prob- lems, put forward relevant quality requirement, refine the entry point of medical record writing, intensify the function of three-level medical record network management and strengthen the assessment of medical record quality. With above measures put into practice, the intensional quality of traditional Chinese medicine medical records can be improved.