中医住院病案内涵质量缺陷探索分析及防范措施

Exploratory Analysis and Preventive Measures of the Defects Connotation about TCM Medical Records

目的旨在分析中医住院病案内涵质量中存在缺陷,分析讨论,探讨适当防范措施,以提高中医住院病案书写质量,保障中医诊疗的医疗质量及安全。方法组成院级病案质量检查小组,对某中医医院各病区在院病案进行随机集中抽查,共计抽查19个病区228份中医住院病案,根据《中医病历书写基本规范》要求,按照某院住院病案质量检查表进行检查,重点审查中医病案内涵质量,并将缺陷进行分析总结。结果归纳出某院中医住院病案内涵质量缺陷,问题主要集中在中医望闻切诊、辨病辨证依据、中医鉴别诊断、初步诊断、理法方药一致性、修改治则及方药未重新辨证、主病主症使用中成药是否进行辨证,以及上级医师查房中医内容缺失或简单空洞、指导作用不足8个方面,其中上级医师查房中医内涵体现及指导作用不突出方面存在的问题最多,占44.98%。结论需提高医务人员对病案质量的认识,通过进行专项培训指导,强化上级医师带教意识,加强科室自查及医院职能部门的环节质控,给予适当奖惩措施,同时也希望国家尽快出台中医住院病案质控评分标准,以达到加强病案质量管理,提高中医住院病案书写质量的目的。

Objective To analyze the defects in TCM medical record connotation quality, to explore the appropriate preventive measures, in order to improve the quality of medical records writing, guarantee medical quality and safety.Methods A hospital level medical record quality inspection team was formed to randomlycheck the medical records with all wards in the TCM hospital. A total of 228 medical records in 19 wards were checked.According to the basic requirements of writing basic norms of TCM medical records, and the quality check list of inpatient medical records in a hospital, the connotation and quality of TCM medical records were reviewed, and the defects were analyzed and summarized. Results The connotation quality defects of inpatient medical records in a hospital were summarized. The problem is mainly concentrated in the Look, listen, question and feel the pulse--four ways of diagnosis, differentiation of symptoms and signs, differential diagnosis of Chinese Medicine, tentative diagnosis, Uniformity of prescription and prescription, modification of treatment and prescription to syndrome differentiation, the syndrome of primary disease treated with proprietary Chinese medicine dialectical, and Doctors＇ rounds of higher levels, lack of TCM content, Lack of guidance. Among them, the higher physician rounds, the connotation and guidance of TCM are not prominent, accounting for 44.98%.Conclusion We should improve the understanding of the medical staff of medical record quality, through special training and guidance, strengthen the physician teaching consciousness, strengthen the process of quality control department and hospital departments self-examination, give appropriate incentives, but also hope that the country as soon as possible introduce TCM hospital medical record quality control standard for evaluation, in order to strengthen the quality management of medical records, improve the quality of medical records writing in traditional Chinese medicine.