南宁市第八人民医院门诊中药处方临床诊断信息规范化情况调查

Investigation on the Standardization of Clinical Diagnosis Information of Traditional Chinese Medicine Prescriptions in Nanning Eighth People’s Hospital

目的 了解南宁市第八人民医院门诊中药处方临床诊断信息规范化情况,发现并分析其中存在的问题,找出解决办法,使南宁市第八人民医院门诊中药处方临床诊断信息规范化达到三级甲等医院标准要求。方法 依据国家中医药管理局、国家卫生健康委员会关于印发《中医病证分类与代码》和《中医临床诊疗术语》的通知和国家中医药管理局颁布的《中药处方格式及书写规范》,按简单针对性抽样方法,从2020年1月、4月、11月、12月抽取处方共929张,调查门诊中药处方临床诊断信息规范化情况。结果 门诊中药处方中,临床诊断信息不规范处方625张,占总样本的67.28%(625/929),分为临床诊断信息中医病证书写不规范和格式不完整处方。其中两者皆有的处方79张,中医病证书写不规范处方432张,仅有疾病名无证候名的格式不完整处方252张。中医病证书写不规范和诊断格式不完整的问题明显。结论 需规范门诊中药处方临床诊断信息。

Objective To understand the standardization of clinical diagnosis information of outpatient Chinese medicine prescriptions in our hospital,find out and analyze the existing problems,and find out the solutions,so as to make the standardization of clinical diagnosis information of outpatient Chinese medicine prescriptions in our hospital meet the requirements of class Ⅲ a hospital. Methods According to the national administration of traditional Chinese medicine According to the notice of the National Health Commission on printing and distributing the classification and code of traditional Chinese medicine (TCM) syndromes and the terminology of TCM clinical diagnosis and treatment,and the standard of TCM prescription format and writing issued by the State Administration of traditional Chinese medicine,929prescriptions were selected from January,April,November and December 2020 according to the simple targeted sampling method,and the standardization of clinical diagnosis information in outpatient TCM department was investigated. Results There were 625 out-patient prescriptions with non-standard clinical diagnosis information,accounting for 67. 28% (625/929) of the total samples,which were divided into non-standard clinical diagnosis information and incomplete format. There were 79 prescriptions for both,432 prescriptions for nonstandard writing of TCM disease and syndrome names,and 252 prescriptions for incomplete format of disease name without syndrome name. It is obvious that the writing of TCM disease certificate is not standardized and the diagnosis format is not complete. Conclusion It is necessary to standardize the clinical diagnosis information of TCM prescriptions in our hospital.