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随着各地中医医院和中医病房的建立,对中医病历的书写日趋规范化,能突出地反映中医学的特点。但是目前中医住院病历的医嘱内容仍然存在着十分迫切的问题。据我们了解目前各单位中医医嘱的内容大同小异,均未能突出中医特色。为了提高医疗护理质量,促进中医事业的发展,谈谈我们对中医病历医嘱内容的看法。一、目前中医病历的医嘱情况: 目前大多数各级中医院住院病历的医嘱记录格式,均按西医病历的格式记录。我们认为格式可以采用,但内容必须要突出中医特色。西医院在长期医嘱栏中,明确地书写所用药物名称、剂量、给药途径、给药时间以及停用时间等使人一目了然地了解治疗方案,随着药物变化又能知道疾病的演变过
With the establishment of TCM hospitals and TCM wards around the world, the writing of TCM medical records is becoming more and more standardized, which can prominently reflect the characteristics of TCM. However, there are still pressing problems in the contents of the current medical records of hospitalized Chinese medicine. According to our understanding, the contents of traditional Chinese medicine doctor’s orders in various units are similar, and none of them have been able to highlight the characteristics of Chinese medicine. In order to improve the quality of medical care and promote the development of Chinese medicine, we talked about our views on the contents of the medical records of Chinese medical records. I. Current medical history of Chinese medical records: At present, the medical record formats of most hospital records in most Chinese hospitals at all levels are recorded according to the Western medical record format. We think that the format can be adopted, but the content must highlight the characteristics of Chinese medicine. In the long-term medical order column, West Hospital clearly stated the drug name, dose, route of administration, administration time, and time of decommissioning so that people can understand the treatment plan at a glance. With the drug change, they can know that the disease has evolved.