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中医病历古称“诊藉”、“病案”、“医案”。病历是中医系统理论与临床实践密切结合的真实记录。病历书写必须严肃认真,实事求是、准确、及时。病历有住院病历和门诊病历之分,住院病历要求在病人入院后24小时内完成,门诊病历则要求当时完成。它要求把病人的祥细病情,过去病史和家庭病史,诊察所得的资料(包括阳性症候及有鉴别价值之阴性症候)以及辨证施治的经
The medical history of traditional Chinese medicine is called “medical lending”, “medical record”, and “medical case”. The medical record is a true record of the close integration of Chinese medicine system theory with clinical practice. The writing of medical records must be serious, truthful, accurate, and timely. The medical records are divided into inpatient medical records and outpatient medical records. Inpatient medical records are required to be completed within 24 hours after admission, and outpatient medical records are required to be completed at that time. It requires the patient’s detailed medical condition, past medical history and family history, information obtained from medical examinations (including positive symptoms and negative symptoms with discriminating value) and syndrome differentiation treatment.