中医个案报告类论文中诊疗信息的描述

Description of Diagnosis and Treatment Information in Chinese Medicine Case Reports

随着现代医学的发展,中西医学相结合被广泛应用于临床诊断、治疗中,中医个案报告的内容也随之发生了变化。通过对目前中医个案报告中诊疗信息报告存在问题的总结与分析,提出诊断信息是个案报告的基础,是其科学性与真实性的客观保证;治疗信息是个案报告的核心,是其学术水平与价值的集中体现;疗效判定信息是个案报告的关键,是个案报告价值评判的依据。应在准确、翔实记录中西医诊断、治疗信息的基础上,着重发挥中医诊断特色与治疗优势,使中医个案报告真正起到提高临床诊疗水平、拓宽诊疗思路、促进理论发展与创新的作用。

With the development of modern medicine,integrated Chinese and western medicine is widely applied in clinical diagnosis and therapy,and the content of case reports in Chinese medicine changes. At present,many Chinese medicine case reports do not reasonably and fully summarize and report diagnosis and treatment information in Chinese and western medicine,in which the lack of important diagnosis and treatment information in Chinese and western medicine severely impact the scientificity,reality and academic levels of Chinese medicine case reports.Based on the summary and analysis of the questions in medical information reports in current Chinese medicine case reports,the authors proposed that diagnosis information is the basis of case reports,which is the objective guarantee of scientificity and reality of case reports. Treatment information is the core of case reports,which reflects the academic levels and value of case reports. Therapeutic effect evaluating information is the key to case reports,which is the basis of value evaluation of case reports. The authors hold that,based on correctly and fully recording the diagnosis,treatment and therapeutic effect evaluating information of Chinese and western medicine,by developing the Chinese medicine diagnostic characteristics,taking the advantages of Chinese medicine treatment and exploring Chinese medicine therapeutic effect evaluating methods,case reports may provide primary clinical data for doctors and medical researchers,and play a role in increasing clinical diagnosis and treatment level,broadening diagnosis and treatment thought and promoting the development and innovation of the theory.