初探中医诊疗方案的评估对中医病案内涵质量的影响

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。

Explore the Impact on the TCM Medical Record Connotation Quality of Assessment of TCM Diagnosis and Treatment Plan

Objective To explore the impact of assessment of TCM diagnosis and treatment plan on the connotation of TCM medical record. Method A total of 40 hospitalized patients are divided into groups in accordance with whether written assessment of TCM treatment. Experts examine the disease course content and score the content of TCM, ideas of diagnosis and treatment, principle and herbs, writing format. Compare the scores of the two groups, and analyze the impact on medical record connotation of the evaluation method. Result After the assessment, the total medical record score （155.63± 8.18） and scores of content about TCM, ideas of diagnosis and treatment, principle and herbs （41.00±4.47,40.25 ± 3.88,40.00±4.73） are higher than that in the control group （140.00±11.18,34.63±4.08,35.75 ± 5.14,32.88 ±4.39）. Condusion The assessment meth- ods of TCM medicine treatment can promote understanding and thinking of the physician on the case, and also improve the quality of TCM medical record connotation.