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目的探讨中医诊疗方案的评估对中医病案内涵质量的影响。方法对40名住院患者按照是否进行中药治疗书面评估进行分组,请评审专家对患者病程内容评分。评分内容包括中医内容、诊治思路、理法方药、书写格式四项。对比以上四项的得分,分析出评估方法对病案内涵的影响。结果经评估后的病历所得总分为155.63±8.18,高于对照组140.00±11.18的总分;其中,中医内容、诊治思路、理法方药项的得分分别为41.00±4.47、40.25±3.88、40.00±4.73,均高于对照组(34.63±4.08、35.75±5.14、32.88±4.39)。结论中药治疗评估方法能够促进医师对病例的认识与思考,提高中医病案内涵的质量。
Objective To explore the impact of TCM diagnosis and treatment programs on the quality of TCM medical records. Methods 40 hospitalized patients were divided into groups according to the written assessment of Chinese medicine treatment. Please review the experts to score the patient’s course content. Scoring content includes TCM content, diagnosis and treatment ideas, law prescriptions, writing format four. Compare the scores of the above four items and analyze the impact of the assessment methods on the connotation of medical records. Results The total score of medical records obtained after evaluation was 155.63 ± 8.18, which was higher than that of the control group (140.00 ± 11.18). Among them, the contents of Chinese medicine, the diagnosis and treatment ideas and the prescription of law prescription were respectively 41.00 ± 4.47, 40.25 ± 3.88 and 40.00 ± 4.73, all higher than the control group (34.63 ± 4.08,35.75 ± 5.14,32.88 ± 4.39). Conclusion Chinese medicine treatment evaluation method can promote physicians to recognize and think of cases and improve the quality of TCM medical record connotation.