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中医病案有着悠久的历史,西汉时期司马迁的《史记.扁鹊仓公列传》是我国现存最早的病案,宋.许叔微的《伤寒九十论》是我国第一部病案专著。明代医家江编集的《名医类案》,是我国第一部中医全科医案专著。1953年卫生部将诊籍、医案、病历统一规范为病案,但无统一的中医病案格式。1983出台的年《中医病历书写格式及要求》,初步统一了全国中医病案书写格式。1991年的《中医病案书写规范》,首次规定了“中医病案首页格式”,为中医临床医疗信息的收集、传播、应用和研究奠定了基础。1998颁布了《中医病案规范》,首次将体格检查与望闻切诊融为一体。2002年为了适应新的医政形势,出台了《中医、中西医结合病历书写基本规范(试行)》,沿用至今。
The history of Chinese medical records has a long history. In the Western Han Dynasty, Sima Qian’s “Historical Records. The Biography of Bian Bao Canggong” is the earliest known medical record in China. Song. Xu Shuwei’s “Stagnation of Thirty-nine Diseases” is the first monograph in China. The “Classical Medical Cases” compiled by the famous physician Jiang Yan in the Ming Dynasty was the first monograph of Chinese medicine in China. In 1953, the Ministry of Health standardized the medical records, medical records, and medical records as medical records, but there was no unified Chinese medical record format. The “Typical Format and Requirements for TCM Medical Record Writing” issued in 1983 has preliminarily unified the writing format of TCM medical records throughout the country. In 1991, the “Standards for Writing TCM Medical Record Cases” stipulated for the first time the “home page format for TCM medical records”, which laid the foundation for the collection, dissemination, application and research of TCM clinical medical information. In 1998, the TCM Medical Record Rules were promulgated, and the first time the physical examination was combined with the observation and diagnosis. In order to adapt to the new medical situation in 2002, the “Basic Rules for the Writing of Traditional Chinese and Western Medicine Records (Trial)” was promulgated and it is still in use today.