住院医师规范化培训中中医病案内涵缺失问题及对策

Inadequate connotation of TCM medical records in standardized training of resident doctors and its countermeasures

目的通过补充中医病案内涵,提高住院医师规范化培训质量。方法随机抽取80份由中医标准化培训医师撰写的中医档案,参照中医病历书写的基本规则,逐项进行检查和分析。结果住院中医病案普遍存在的问题是中医病案内涵不完整、不完善,主要表现在四诊记录、辨证依据、三级查房记录等方面。结论通过调查,实施一系列提高住院医师规范化培训质量的对策,包括培训师知识技能、书写能力、三级查房要求、中医病案内涵评估等。

Objective This paper aims at improving the quality of standardized training of resident doctors by complementing the connotation of TCM medical records.Method A total of 80 archived TCM medical records written by TCM standardized training of resident doctors were randomly selected,and the medical records were examined and analyzed item by item with the reference to"Basic Rules for Writing Chinese Medical Records".Results The common problem of hospitalized TCM medical records was that the connotation of TCM medical records was incomplete and inadequate mainly in the recording of the four diagnostic examinations,dialectical basis,and"three-level"ward rounds.Conclusion Through the investigation,a series of countermeasures are implemented to improve the quality of standardized residents training,including trainers’knowledge and skills,their writing ability,requirements of"three-level"ward rounds and assessment of connotation of TCM medical records.