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病历是医生对患者诊治过程中详细的,真实的记录。既是医学理论与临床经验相融化的产物,又是工作态度、服务质量的联合体现。在一定场合,病历又作为法律依据之一。而中医病历,更具有其民族的医学特色和文学艺术。随着中医机构的建立和完善,在振兴中医,发挥中医优势、弘扬中医特色的大好形势下,对中医病历提出了高标准、严要求。为了提高中医病历质量,促进管理规范化,我们对五所县级中医医院的住院病历进行了抽样调
The medical record is a detailed and real record of the doctor’s treatment of the patient. It is not only the product of the fusion of medical theory and clinical experience, but also the embodiment of work attitude and service quality. On certain occasions, the medical record serves as one of the legal basis. The medical history of Chinese medicine has its own medical characteristics and literary arts. With the establishment and improvement of traditional Chinese medicine institutions, in the revitalization of traditional Chinese medicine, giving full play to the advantages of traditional Chinese medicine, and promoting the characteristics of traditional Chinese medicine, it has put forward high standards and strict requirements for the history of Chinese medicine. In order to improve the quality of Chinese medical records and promote the standardization of management, we sampled the inpatient records of five county-level Chinese medicine hospitals.