【摘要】 目的 分析北京地区中医医院病案缺陷分布情况及原因，为制定相应对策提供依据，从而提升病案质量。方法 调取北京市55家二、三级中医医院2023年度每月10日出院的随机归档中医或中西医结合类别病历20份,其中包括10份综合内科病案、5份手术病案，5份中医特色病案，总计1100份。采用《2023年度北京市中医病案内涵检查表》(设定4个一级指标和分属的18个二级指标)评价病案理法方药一致性、查房指导作用、病案个体化体现和绩效考核指标四方面情况并进行数据分析，统计结果采用扣分比(指标总扣分/指标总分)的形式进行展示。结果 一级指标中，理法方药一致性和查房指导作用扣分比例最高，其中三级医院理法方药一致性部分扣分比例最高(17.89%)，二级医院查房指导作用部分扣分比例最高(26.16%)。三级医院与二级医院相比，在理法方药一致性(t=-2.339,P=0.023)、查房指导作用(t=-4.398,P=0.000)及病案个体化体现(Z=-2.039,P=0.041)三方面上优于二级医院，有统计学差异(P<0.05)。二级指标中，在中医治疗合理性、上级医师查房中医指导作用部分扣分比例最高。三级医院理法方药一致性中的中医治疗合理性、查房指导作用中上级医师查房中医指导作用部分扣分比例最高(32.36%)，二级医院查房指导作用中的上级医师查房中医指导作用部分扣分比例最高(45.63%)。三级医院与二级医院相比，四诊信息舌脉一致性(t=-2.588,P=0.012)、辨证分析逻辑性(t=-2.083,P=0.042)，上级医师查房西医指导作用(t=-4.665,P=0.000)、上级医师查房中医指导作用(t=-2.743,P=0.008)和首程病例特点体现(t=-2.603,P=0.012)五个方面明显优于二级医院，有统计学差异(P<0.05)。尤其在上级查房西医指导作用和中医指导作用方面，有显著统计学差异(P<0.01)。结论 理法方药一致性欠缺和上级查房指导作用体现不足是北京市中医医院病案内涵质量存在的主要问题。应以加强中医内涵质控为主要抓手。增强与临床医师沟通协作，持续提高临床医师中医基本功。从而提高病案书写和病案管理质量，保证医疗安全。更多还原

【Abstract】 Objectives This paper analyzed the distribution and causes of defects in medical records of traditional Chinese Medicine Hospitals in Beijing area, and provided basis for formulating corresponding countermeasures, so as to improve the quality of medical records and medical service quality of Traditional Chinese Medicine Hospitals. Methods A total of 1100 medical records were collected from 55 secondary and tertiary Traditional Chinese Medicine Hospitals in Beijing in 2023, including 10 comprehensive internal medicine records,5 surgical records and 5 TCM characteristic medical records. Using the "2023 Beijing TCM Medical Record Connotation Examination Table"(set 4 first-level indicators and 18 second-level indicators). The four aspects of medical record theory, prescription and medicine consistency, ward round guidance, individualized manifestation of medical record and performance assessment indicators were evaluated and data were analyzed. Statistical results were displayed in the form of deduction ratio(total deduction of indicators/total score of indicators).Results Among the primary indexes, the proportion of deduction for the consistency of prescription and medicine and the guiding function of ward rounds was the highest, among which the proportion of deduction for the consistency of prescription and medicine was the highest in tertiary hospitals(17.89%), and the proportion of deduction for the guiding function of ward rounds in secondary hospitals was the highest(26.16%). Compared with secondary hospitals,tertiary hospitals were superior to secondary hospitals in three aspects: consistency of theory, prescription and medicine(t=-2.339, P=0.023), guidance function of ward rounds(t=-4.398, P=0.000) and individualized manifestation of medical records(Z=-2.039, P=0.041), with statistical difference(P<0.05). In particular,there was significant statistical difference in the guiding effect of ward rounds(P<0.01). Among the secondary indexes, the proportion of deduction was the highest in the rationality of TCM treatment and the guidance role of superior doctors in ward rounds. The proportion of deduction for TCM treatment reasonableness and guidance of ward rounds by superior physicians was the highest(32.36%) in the consistency of theory, prescription and medicine in tertiary hospitals, and the proportion of deduction for the part of guidance of ward rounds by superior physicians was the highest(45.63%) in the part of guidance of ward rounds in secondary hospitals. Compared with secondary hospitals, tongue and pulse consistency of four diagnosis information(t=-2.588, P=0.012), logic of syndrome differentiation analysis(t=-2.083, P=0.042), the guiding role of superior physicians in ward rounds of western medicine(t=-4.665, P=0.000), the guiding role of superior physicians in ward rounds of Chinese medicine(t=-2.743, P=0.008) and the characteristics of the first case(t=-2.603, P=0.012) were significantly better than those of secondary hospitals, with statistical differences(P<0.05). In particular, there was significant statistical difference between the guiding effect of western medicine and Chinese medicine on superior rounds(P <0.01). Conclusions The main problems in the quality of medical records in Beijing Hospital of Traditional Chinese Medicine were the lack of consistency of principles, methods, prescriptions and medicines and the lack of superior guidance in ward rounds. To improve the quality of medical records in TCM hospitals, on the one hand, we should strengthen the quality control of TCM connotation. On the other hand, we should strengthen communication and cooperation with clinicians, continuously improve the basic skills of TCM of clinicians, and enhance the guiding role of high-level physicians, so as to improve the quality of medical record writing and medical record management,and ensure medical safety.更多还原