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目的通过对中医院运行病历质量评价标准的研究,提高中医病案质量。方法回顾某中医院2006年-2010年住院运行病历环节质控情况,并用问卷调研、访谈的方法,征求临床医师意见,探讨中医病案质量评价标准。结果 5年间运行病历检查发现问题共5876条,中医内涵质量缺陷占13.85%,集中在四诊信息、辨病辨证依据、理法方药、上级医师查房等方面。共回收有效问卷249份,调查结果显示85%以上的医师认同医院现行的病案质量评价标准,书写病历的下级医师重视病案的实用性,上级医师更注重病案内涵及学术研究价值。结论中医运行病历质控应围绕医疗安全核心制度,建立全国统一标准,突出体现中医内涵特色,在保证病案质量的基础上,平衡各项检查项目的权重,使评价标准更切合临床实际。
Objective To improve the medical record quality of TCM by studying the evaluation standard of medical records in Chinese medicine hospital. Methods To review the quality control of medical records of a hospital during 2006 to 2010 in a Chinese medicine hospital, and to seek the opinions of clinicians by means of questionnaire survey and interviews, to discuss the evaluation criteria of the quality of medical records of Chinese medicine. Results A total of 5876 medical records were found during the five years of operation. The quality defects of TCM connotation accounted for 13.85%, focusing on the four diagnostic information, the basis for differentiation of symptoms and signs, the prescription of prescriptions, and the investigation by superior physicians. A total of 249 valid questionnaires were collected. The survey results showed that more than 85% of the doctors agreed with the current hospital medical record quality evaluation standard. The lower physicians who wrote the medical record attached importance to the practicality of the medical record. The superior physicians paid more attention to the connotation of the medical record and academic research value. Conclusion The quality control of medical records should focus on the core system of medical safety, establish a unified national standard, highlight the connotation and characteristics of traditional Chinese medicine, balance the weight of each item on the basis of ensuring the quality of medical records, and make the evaluation standard more suitable for clinical practice.