主 办:北 京 中 医 药 大 学
ISSN 1003-305X CN 11-1349/R

中医教育 ›› 2021, Vol. 40 ›› Issue (1): 79-81.doi: 10.3969/j.issn.1003-305X.2021.01.324

• 教学园地 • 上一篇    下一篇

住院医师规范化培训中中医病案内涵缺失问题及对策

李潇1, 国佳鑫2, 蔡和平3, 祁烁1, 董青1#, 侯丽1, 杨盼1   

  1. 1 北京中医药大学东直门医院 北京 100700;
    2 北京中医药大学 北京 100029;
    3 首都医科大学附属北京中医医院 北京 100010
  • 收稿日期:2019-11-15 发布日期:2021-01-29
  • 作者简介:李潇, 女, 博士, 副主任医师
  • 基金资助:
    *北京中医药大学教育科学研究课题(No. XJZX17071),中医药高等教育学会临床教育研究会临床教学科学研究课题,北京市中医管理局中医住院医师规范化培训三优教学团队项目

Inadequate connotation of TCM medical records in standardized training of resident doctors and its countermeasures

Li xiao1, Guo Jiaxin2, Cai Heping3, Qi Shuo1, Dong Qing1#, Hou Li1 , Yang Pan1   

  1. 1 Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700;
    2 Beijing University of Chinese Medicine, Beijing 100029;
    3 Beijing Traditional Chinese Medicine Hospital Affiliated to Capital Medical University, Beijing 100010
  • Received:2019-11-15 Published:2021-01-29

摘要: 目的 通过补充中医病案内涵,提高住院医师规范化培训质量。方法 随机抽取80份由中医标准化培训医师撰写的中医档案,参照中医病历书写的基本规则,逐项进行检查和分析。结果 住院中医病案普遍存在的问题是中医病案内涵不完整、不完善,主要表现在四诊记录、辨证依据、三级查房记录等方面。结论 通过调查,实施一系列提高住院医师规范化培训质量的对策,包括培训师知识技能、书写能力、三级查房要求、中医病案内涵评估等。

关键词: 中医, 住院医师规范化培训, 中医病案, 内涵, 对策

Abstract: Objective This paper aims at improving the quality of standardized training of resident doctors by complementing the connotation of TCM medical records. Method A total of 80 archived TCM medical records written by TCM standardized training of resident doctors were randomly selected, and the medical records were examined and analyzed item by item with the reference to “Basic Rules for Writing Chinese Medical Records”. Results The common problem of hospitalized TCM medical records was that the connotation of TCM medical records was incomplete and inadequate mainly in the recording of the four diagnostic examinations, dialectical basis, and “three-level” ward rounds. Conclusion Through the investigation, a series of countermeasures are implemented to improve the quality of standardized residents training, including trainers’ knowledge and skills, their writing ability, requirements of “three-level” ward rounds and assessment of connotation of TCM medical records.

Key words: traditional Chinese medicine, standardized training of resident doctors, TCM medical record, connotation, countermeasure

中图分类号: 

  • G642.46