基于病例报告规范指南对近5年中医病案质量的评价研究＊

目的 对发表于《中国针灸》、《中医杂志》、《中华中医药杂志》的病例报告进行质量评价,以期推动中医病案报告的规范化、标准化、国际化。方法 电子检索2016-2020年近5年间,发表于《中国针灸》、《中医杂志》、《中华中医药杂志》杂志上的病例报告。采用“病例报告撰写CARE（CAse REport checklist）规范指南”进行评估,内容包括标题、摘要词、关键字、时间表、引言、患者基本信息、体格检查、诊断评估、干预措施、结局、随访、患者观点、知情同意书、致谢部分与伦理学说明等。结果 共纳入430篇中医病例报告。根据统计可知,病例报告类文献数量呈逐年上升趋势,以《中华中医药杂志》记载的中医类病例报告数量最多。具体数据为：《中华中医药杂志》（277）、《中医杂志》（110）、《中国针灸》（42）。其中病例报告的标题、背景信息、关键词等汇报内容较完整（85%以上）。但纳入的病例报告整体质量评分较低387篇（89.77%）,高质量病例报告仅有43篇（10.23%）,其中含有低质量病例报告47篇（10.93%）。结论 中医类病例报告文献研究虽发展势头良好,近几年大量的病例报告类文献不断涌现,内容创新,对临床与教学均有较大的帮助,但现有病例报告质量偏低,医者在撰写病例报告时仍偏向于按古典医籍中病例报告的模板进行撰写,未能与国际规范要求很好的接轨。建议今后本领域能根据中医其自身的特点与国际规范相结合,制定出适用于中医的病例报告规范指南,以提高病例报告质量。

Evaluation and Research on the Quality of TCM Medical Records in the Past 5 Years Based on the Standard Guide for Case Reports

Objective To conduct quality evaluation of case reports published in Chinese Acupuncture and Moxibustion, China Journal of Traditional Chinese Medicine and Pharmacy, Journal of Traditional Chinese Medicine, with a view to promoting the standardization and internationalization of traditional Chinese medicine (TCM) case reports.Methods Electronic retrieval of case reports published in the Chinese Acupuncture and Moxibustion, China Journal of Traditional Chinese Medicine and Pharmacy, Journal of Traditional Chinese Medicine in the past 5 years from 2016 to 2020 was conducted. We used the Case Report Writing CARE Standard Guidelines for evaluation, which includes title, keywords, abstract, introduction, timetable, patient, informa tion, physical examination, diagnostic evaluation, intervention, follow-up and outcome, patient views, informed consent, acknowledgement and ethics etc.Results According to statistics, the number of case report documents was increasing year by year, and the number of TCM case reports recorded in China Journal of Traditional Chinese Medicine and Pharmacy among which was the largest. Specific data were Chinese Acupuncture and Moxibustion (42), China Journal of Traditional Chinese Medicine and Pharmacy (277), Journal of Traditional Chinese Medicine (110). The title, background information, keywords and other reports were relatively completed (over 85%). However, the overall quality of the included case reports was about 387 (89.77%) of lower quality, only 43 (10.23%) of high-quality case reports, and about 47 (10.93%) of low-quality case reports.Conclusion According to the 430 cases after screening, the report shows that although the publication of medical records has been increasing year by year, constantly emerging in recent years a large number of case report class literature, content innovation, have significant help for clinical and teaching the quality of existing case reports is low. When writing case reports, doctors still prefer to write case reports based on the template of case reports in classical medical records, which fails to meet the requirements of international standards. It is recommended that in the future, this field can combine the characteristics of Chinese medicine with international norms to formulate a standard guide for case reporting applicable to Chinese medicine to improve the quality of case reports.