中医住院病案内涵质量缺陷探索分析及防范措施

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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。 The aim is to analyze the shortcomings of the connotation of TCM medical records, to analyze and discuss appropriate preventive measures to improve the quality of medical records and to ensure the medical quality and safety of TCM diagnosis and treatment. Methods The hospital-level medical record quality examination team made a random sampling of randomly selected medical records in a ward of a Chinese medicine hospital. A total of 228 Chinese medical records were collected from 19 wards. According to the requirements of Basic Medical Record Writing Rules, Check the quality of medical records checklist, focusing on reviewing the quality of TCM medical records, and the defects were analyzed and summarized. Results Summarize the quality defects of hospital inpatient medical records in a hospital. The problems mainly focus on the traditional Chinese medicine (TCM), clinical diagnosis, evidence based diagnosis, differential diagnosis of TCM, preliminary diagnosis, consistency of prescriptions, revision and cure, The main symptoms of proprietary Chinese medicine is dialectical, as well as superior physician rounds out the Chinese content is missing or simple hole, the role of guidance in less than 8 aspects, including superior physicians rounds out the meaning of Chinese medicine and guidance does not highlight the problems that exist, accounting for 44.98% . Conclusion Medical staffs need to improve their understanding of the medical records. Through specific training and guidance, they should reinforce their sense of teaching, improve the self-inspection of departments and the functional control of hospitals, and give appropriate rewards and punishments. At the same time, they also hope that the State will introduce TCM inpatients Quality control criteria for case-control, in order to achieve the goal of strengthening the quality management of medical records and improving the quality of written medical records in Chinese medicine.
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